Three Dimensional Imaging in Orthodontics 5-Email

Al-Azhar University
Faculty of Dental Medicine

Orthodontic Department
Three Dimensional imaging in orthodontics

By
El-Hassanein Hussein El-Hassanein
(B.D.S., M.SC)
Assistant lecturer, Orthodontic Department
Al-Azhar University
(Boys-Cairo)
Under supervision of
Dr. Ramadan yousof abou shahba
(B.D.S., M.SC, Ph D)
Lecturer of Orthodontics
Al-Azhar University
(Boys-Cairo)
1430 H –2009 G
1 http://dentalbooks-drbassam.blogspot.com
Introduction
Historical background
Why do we need a three-dimensional record?
The Limitations of Radiographic Cephalometry
What does it mean to have a three-dimensional image and how is it obtained?
General 3D concepts
What is a possible classification of these devices?
Three-Dimensional Technologies
The Digigraph™
The computer
Laser scanning (3D laser scanning)
Vision-based scanning techniques
Moiré topography
Structured light
Stereophotogrammetry
3D Facial Morphometry (3DFM)
Magnetic resonance imaging and surface scanning
Conventional computerized tomography (CT)
Cone-beam computerized tomography (CBCT)
Video camera
Sonic digitizing
Complete 3d patient records
Classification of three dimensional orthodontic records
A) The Three Dimensional Face (3D imaging of the face)
B) The Three Dimensional Craniofacial Skeleton
C) The Three Dimensional Dentition
3-D Cephalometric Imaging Versus Traditional 2-D Approach
A comparison of three-dimensional and two-dimensional analyses of facial motion
Three-Dimensional Cephalometry
What are some clinical applications?
Facial Growth
Average Faces and Superimposition
2
http://dentalbooks-drbassam.blogspot.com
Facial Analysis
Surgical Evaluations
Surgical patients and those with syndromes and clefts
Impacted Teeth and Oral Abnormalities
Airway Analysis
Assessment of Alveolar Bone
Alveolar bone resorption and the center of resistance modification
Root resorption
Arch length analysis
Temporomandibular Joint (TMJ) Morphology and Assessment
Tongue size and Posture
Planning for placement of dental implants
Analysis of tooth movement in extraction cases
Integration of digital dental casts in 3-dimensional facial photographs
Three-dimensional measurement of residual adhesive and enamel loss on teeth after
debonding of orthodontic brackets
What types of analysis are available?
Where are we with this technology?
Are there limitations in the systems?
Reliability of a three dimensional method for measuring facial animation:
Evaluation of the Validity of Tooth Size and Arch Width Measurements Using
Conventional and Three-dimensional Virtual Orthodontic Models
Radiation exposure
What are the costs involved?
What is the best clinical setting for the different imaging devices?
Are there medico-legal issues with these devices?
What does the future hold?
References
3
Introduction
In the last 10 years, digital procedures have been progressively introduced in
the orthodontic practice. The process started introducing digital photography,
followed by digital radiology, and in the last five years, by the introduction of
digital models. Quality has also progressively increased during the years due to
continuous enhancement of the technology involved in all these fields, and today
it seems that the quality level obtained is high.
The use of lateral cephalometric radiographs forms an important diagnostic tool

in orthodontic treatment as well as orthognathic surgery. However, their 2
dimensional nature presents an inherent limitation to the clinician, as the human
body is 3 dimensional. In addition, a significant amount of radiographic projection
error further limits their accuracy. Photographic and radiographic methods were
quickly adopted; however, using two dimensional methods to represent a three
dimensional entity can result in misleading or incomplete diagnostic information.
Three-dimensional imaging of the human body via computed tomography has
been available to the field of medicine for the last 30 years. However, the
significant amount of radiation exposure associated with this technology,
precluded its widespread use in dentistry. With the development of Cone Beam
Computed Tomography, there has been a drastic reduction in radiation exposure
to the patient, which allows its use for safely obtaining 3 dimensional images of
the craniofacial structures. This should allow the clinician to visualize the hard
and soft tissues of the craniofacial region from multiple perspectives, which could
have far-reaching implications for treatment planning in orthodontics and
orthognathic surgery.
Tracing lateral x-rays directly on PC monitors using both linear and angular
measurement of the teeth, maxilla, mandible and cranial base became very
extended to the daily practice with digital methods. Today, almost all
4
cephalometric analyses are available within the most sophisticated imaging
software.
Also with digital models, it became very common and useful to make digital
measurements in order to evaluate, for example, both the dento-dental and the
dento-alveolar discrepancy. An important push to the use of digital models has
been represented by the acceptance of this analysis by the ABO few years ago. In
the last few years, the CAD (Computer Aided Design) and the CAM (Computer
Aided Manufacturing) technology has been applied to dentistry, especially in
orthodontics.
At the beginning of the 20th century, plaster was the primary material used to
capture dentofacial morphology. Almost all practitioners used plaster to make
casts of the teeth and alveolar bone. These dental casts, along with a careful
clinical examination of the patient, formed the database for orthodontic diagnosis
and treatment planning.
Recent advances in digital photography have reduced the cost and improved the
quality of digital cameras. A similar trend in digital radiography also is occurring,
but the acceptance of digital X-ray machines has not been as popular as digital
photography, probably because of the hardware’s price. Dental casts, the oldest
and only remaining 3D record, also have a digital version. Since incorporation in
the market about 5 years ago, 3D digital casts have steadily gained acceptance.
This is due to clinicians’s familiarity with the use of 3D digital models with
invisalign and the practical problems associated with storage of dental casts.
However, there remains some resistance to the digital model from practitioners
accustomed to the touch and feel of this time-honored record. In addition, the
current process used to generate digital study casts still requires dental
impressions. As these existing records become digital, the next logical step is to
combine them to create an integrated digital record of the patient’s dentofacial
morphology. This combination would make the access, storage, and use of this
record more practical. Interestingly, the amount of diagnostic information
5
provided by this new digital record would not be increased. Because the two
dimensional digital records (photographs and cephalograms) remain in 2D. The
record could be improved if a hybrid digital record combined the lateral and
frontal cephalograms to generate a 3D grid to register the dental models.
However, this technique is time-consuming and not practical in a busy
orthodontic office.
Both the orthodontic 3D diagnosis and treatment planning was introduced to
the clinical work producing, for example, a virtual digital indirect bonding method
and a system based on the production of clear aligners to move teeth instead of the
common orthodontic braces. In both systems, a CAD phase and a CAM phase are
forecasted.
In this era of burgeoning biotechnology, the orthodontic profession has entered
a pivotal period— one that will continue to change the practice of orthodontics.
Electronic measurement, storage, analysis, and extrapolation of useful data is part
of this change. A 3-D computerized analysis of the head and face is now
available, providing the clinician with a wealth of information previously
unattainable. The advances of three-dimensional (3D) technology have
accelerated at a tremendous pace over the last two decades with newer machines
and advanced software support. This now means that applications for the clinical
settings can be created and used in routine diagnosis, treatment planning, and
patient education.
Digital records definitely improve storage, access, conservation,
communication, and duplication capabilities, but only a switch to a complete 3D
image of the patient would also incorporate more diagnostic information.
Orthodontists will find that these advances will also impact the profession, and
this seminars aims to give tile reader the basic foundation on which to understand
this interesting and exciting topic.
6
Historical background
From the introduction of the cephalostat, Broadbent stressed the importance of
coordinating the lateral and postero-anterior cephalometric films to arrive at a
distortion-free definition of skeletal craniofacial form.1
The first reports on implementation of this method were by Singh and Savara 2
on 3D analysis of maxillary growth changes in girls. Computer programs have
since been developed to collect three-dimensional coordinates directly from
digital cephalogram images, eliminating the need for hand tracing and mouse-
based X–Y digitizing tablets. 3
Stereophotogrammetry has evolved from old photogrammetric techniques to
provide a more comprehensive and accurate evaluation of the captured subject.
This technique uses one or more converging pairs of views to build up a 3D
model that can be viewed from any perspective and measured from any direction.
The earliest clinical use of stereophotogrammetry was reported by Thalmann-
Degan in 1944 (according to Burke and Beard4) who recorded change in facial
morphology produced by orthodontic treatment. With great advances in computer
technology, a new generation of computerized stereophotogrammetric techniques
has arisen making the capturing and building procedures quicker, simpler and
more accurate. On the other hand, the first commercial Computerized
Tomography (CT) scanner appeared in 1972. Soon after, it was apparent that a
stack of CT sectional images could be used to generate 3D information. In the
early 1980s, researchers began investigating 3D imaging of craniofacial
deformities. The first simulation software was developed for craniofacial surgery
in 1986. Shortly after, the first textbooks on 3D imaging in medicine appeared
with a concentration on the principles and applications of 3D CT- and MRI-based
imaging. 4, 5
Why do we need a three-dimensional record?
The short answer to this question is that our patients are 3D and, therefore, the
same format would be the most accurate representation of their morphology. In
7
traditional cephalometry, 3D craniofacial structures are projected onto 2D
radiographic film. This process creates cephalometric structures and landmarks
that do not exist in the patient. Examples of such structures are the mandibular
symphysis, articulare, the pterygoid fossa, and the “key ridge.” Although
orthodontists around the world constantly refer to these structures as anatomic
landmarks, they are in fact artifacts of the cephalometric technique.
Another problem arises when bilateral structures are averaged to create a
unified anatomic outline. An example of this process is the averaging of the right
and left inferior borders of the mandible to create the “mandibular plane.”
Such averaging of bilateral structures creates two problems.
First, the “plane” that is created is really a line that is an abstraction based on
the anatomy of the patient. Second, averaging the structures results in a loss of
parasagittal information, and any true asymmetry of the patient is lost.
It is impossible to determine how important this lost information is to diagnosis
and treatment planning. 5
The Limitations of Radiographic Cephalometry

The limitations of and problems associated with radiographic cephalometry are
well known. They include image; 6
• Enlargement,
• distortion,
• exposure to radiation,
• chemical hazards (environmental and those due to processing),
• weaknesses of landmark identification,
• inaccurate duplication of measurements,
• significant variation in the position of reference points, such as sella
turcica,
• extremely limited in assessing soft tissue balance,
8
• the study of the shape of the head as a tridirectional problem, the lateral
cephalometric radiograph is a method designed to study two of these
dimensions.
What does it mean to have a three-dimensional image and how is it obtained?

Three-dimensional image reconstruction is a complex task using mathematical
principles. The 3D image is essentially an object that appears to have an extension
in depth. In photography, a 3D image is reconstructed by the principles of
stereoscopic vision when two images are pieced together from two or more
cameras at known distances and angles. In radiography, multi-slice or multi-views
of an object are cleverly reconstructed using complex mathematical algorithms to
produce a representation of the object. 7
General 3D concepts
Before exploring the different techniques available, it is necessary to
understand some of the principles and terminology in 3D imaging. In two-
dimensional (2D) photographs or radiographs, there are two axes (the vertical and
the horizontal axes), while the Cartesian
coordinates system in 3D images consists of
the x-axis (or the transverse dimension), y-
axis (or the vertical dimension), and the z-
axis (the anteroposterior dimension ‘depth
axis’). 8
Right-handed xyz coordinates system
9
3D models are generated in several steps. The first step, ‘Modeling’, uses
mathematics to describe the physical properties of an object. The modeled object
can be seen as a ‘wireframe’ (or a ‘polygonal mesh’). The mesh is usually made
up of triangles or polygons and it is used as a mode of visualization. A part of the
modeling procedure is to
add a surface to the object
by placing a layer of pixels
and this is called ‘image’ or
‘texture mapping’. The
second step is to add some
shading and lighting, which
brings more realism to the
3D object. The final step is
called ‘rendering’, in which
the computer converts the
anatomical data collected
from the patient into a life-
like 3D object viewed on
the computer screen. 8, 9
Texture images captured by color cameras are mapped onto the 3D model to produce the ‘photorealistic rendered model’. In order to
cover the face from ear to ear, two texture maps are captured from two different angles in front of the face. These images are taken
simultaneously to prevent any error due to change in facial expression
10
What is a possible classification of these devices?
Three-dimensional images may be obtained in a variety of ways. 7
TABLE 5-1 Tabular Representation of Surface Imaging Devices
METHOD SOURCE INDUSTRY EXAMPLES

Direct Contact Manual Probe a.Polhemus SSpace Digitizer
b. ELITE
Photo-grammetry Conventional a.Stereo-photogrammetry
lasers 670-690 nm a. Fixed Units

Class I or li FOA • Medical Graphics and Imaging Group,
approved laser UCL ,Cyberware Laboratory 3030 / SP
lights • Others
670-690 nm b. Portabte and Mobile
Class! or il PDA • Minolta Systems (Model versions
- approved laser 700,8890, 8900,89i)
lights • Polhemus hand-held (FASTSCAN)
Structured Light Distorted light a. Single Camera
patterns and b. Multiple Camera
photogrammetric Moire patterns
light capture OGIS Range Finder FSFX-IV
CAM, three-dimensional Shape system
CSD-dimensional Stereo-photogrammetry
(Glasgow)— Computer aided
3dMD™ Pace System .
Others
Video-Imaging Video- a. Motion-Analysis™
sequencing
Radiation Sources Radiation pulses a. CT Scans
b. Cone Beam CTs
Others a. MRI
b. Ultrasound
11
Three-Dimensional Technologies
Ideally, direct measurement in three dimensions would be the most accurate
way to analyze size, shape, and form of the head and face. The head and face
would be scanned by means of a laser and ultrasonic scanner, and the hard and
soft tissue topography electronically recorded. The size, shape, and position of
structures would thus be analyzed, points and planes described, and distances and
angles measured. Comparisons between the respective parts would readily be
made, and any changes in size, shape and position measured. Comparisons would
also be made with other patients. Unfortunately, however, the cost of such
equipment is currently prohibitive for routine clinical use. 6
Although measurements can be made manually using modern calipers and
craniometric equipment, craniometry is slow and tedious. Direct measurement
with calipers intraorally is even more difficult. Today, with the advent of
videoimaging and noninvasive magnetic capabilities (eg, magnetic resonance
imaging), it is possible to produce cephalometric information that combines many
features of manual craniometric techniques and radiographic cephalometric
techniques. Furthermore, information previously unattainable can be analyzed.
One videoimaging computer capable of generating a 2-D or 3-D facial analysis
is the Digigraph. 6
The Digigraph™
The Digigraph, developed by Dr Mark Lemschen. and Mr
Gary Engel, comprises a computer, a monitor and keyboard,
an RGB videocamera with light source, a sonic digitizing
probe with receptor microphones, and a patient seat with a
head holder to stabilize the patient during digitizing .
With the Digigraph, any point can be located in the three
planes of space. Each point is transferred by the Digigraph into the x, y, and z
planes of space. Each point in the 3-D analysis thus has three components. 6
12
X Axis (anterior-posterior). Measurements are made from
the desired point to the anterior facial plane along the x axis.
Y Axis (vertical). Measurements are made from the
desired point to the superior facial plane.
Z Axis (sagittal). Measurements are made from the desired
point to the midsagittal plane.
The computer
The computer used is a Pentium with an optical disk storage system capable of
storing 1,500 full patient records on a single disk. These include extraoral and
intraoral photographs and cephalometric measurements before and after treatment,
as well as progress records during treatment. Progress photographic records can
be captured with a keystroke as often as desired, and these can be retrieved easily
from a monitor at chairside. Prediction images can also be made and stored. Any
study models can be captured and stored as can patient radiographs or records that
clinicians wish to store and retrieve at future patient visits. Electronic storage of
complete patient records is convenient, efficient, and immediate. The transfer of
records to other offices on a floppy disk or via modem is also possible. 6
Laser scanning (3D laser scanning)

Laser scanners are useful for 3-D imaging of the surface of soft tissues of the
face. Scan times of a human face range from 2 to 20 seconds to provide a surface
image map. This topographic image can be viewed on a computer monitor and
manipulated or analyzed in three dimensions. Since the laser does not provide
color information, some laser scanners are calibrated with a color camera to
provide a superimposed high-resolution photo-quality image. Laser scans taken
from different views and at separate moments in time can be fused together.
Images taken from behind and above the subject generate a complete head and
face in 3-D. Since hair does not reflect laser light, the computer generates a
13
somewhat imprecise likeness of the hair. However, accurate hair imaging is not
necessary for routine orthodontic cephalometric analysis.10
The laser-based methods use the same principles as do light-based systems.
However, instead of a light pattern being distorted, a laser pattern is used, and its
distortions are interpreted as 3D information. As with the light-based systems,
laser-based systems are available that image one perspective at a time or in a
panoramic fashion with the laser mounted on a revolving arm. An additional
camera usually is necessary to obtain color information and texture maps.11
Laser scanning provides a less invasive method of capturing the face for
planning or evaluating outcome of orthodontic or orthodontic-orthognathic
surgical treatment. However, this technique has several shortcomings for facial
scanning. They include: 12
• the slowness of the method, making distortion of the scanned image
likely;
• safety issues related to exposing the eyes to the laser beam, especially in
growing children;
• inability to capture the soft tissue surface texture, which results in
difficulties in identification of landmarks that are dependent on surface
color;
• Even with the new white-light laser approaches that capture surface
texture color, the shortcomings persist.

These techniques are totally non-invasive, non-contact and vision-based
imaging systems.
Moiré topography
14
Moiré topography delivers 3D information based on the contour fringes and
fringe intervals. Difficulties are encountered if a surface has sharp features. Better
results can be obtained on smoothly contoured faces. However, great care is
needed in positioning the head, as a small change in head position produces a
large change in fringe pattern. A 3D facial measuring system was proposed by
Motoyoshi et al., 13 but this system does not capture the normal facial texture and
subsequent landmark identification is difficult.
Structured light
Structural light can also produce an accurate 3-D image. A structured light
source projects either circles or grids of light onto the subject's face. A digital
camera records the reflected light as 3-D information, which can be used to
produce a surface map of the face. Typically, a system is calibrated according to
the pattern of light that is projected; two or more projectors and cameras can be
synchronized to take sequences of images from different views. Pattern
interference does not allow multiple views to be taken simultaneously. The serial
images are recorded and a 3-D composite image is generated. 10
The light-based method is also known as the shape camera or the stereo
photogrammetric method. It uses conventional cameras mounted at different
angles to provide different views of a subject. All cameras simultaneously are
activated and all resulting views are combined into a 3D view of that subject.
Usually only one or two of the cameras used is a color camera, and the image
from that camera is the source of color for the 3D image. 8
The shape camera uses the principle of stereophotogrammetry, which is one of
the primary ways humans perceive shape. The number of cameras used in a shape
camera varies according to manufacturers. A vertical stripe or a grid pattern is
projected on the subject at the moment the image is captured. The distortion in
this pattern is captured by the shape lenses. These distortions are interpreted as 3D
information by the computer software. 11
15
Multiple views are then obtained by using multiple cameras systems, or by
taking a sequence of pictures when using single camera systems. The multiple
views are then manually, semi-automatically, or automatically stitched together to
produce a 3D facial model. 11 The alignment is done by designating three or more
correspondent landmarks on overlapping images. After the alignment, a computer
program merges the images, discards duplicate data, smoothes the model’s edges,
blends the colors evenly, and fills holes that may have occurred due to shadows or
reflection. 8
In the structured light technique, the scene is illuminated by a light pattern and
only one image is required (compared with two images with
stereophotogrammetry). 8
Techalertpaisarn and Kuroda14 used two LCD projectors, charge-coupled
device (CCD) cameras, and a computer to produce a three-dimensional image of
the face that can be edited, shifted or rotated easily in any direction. This system
needs at least 2 seconds to capture an image, which may be too long to reliably
avoid head movements, especially when dealing with children.
Stereophotogrammetry has been used for
craniofacial imaging for more than 50 years.
Two or four cameras are configured to capture
a pair of stereo images of the topographic
surface of a patient's face. Through
Sophisticated stereo algorithms, a geometric
calculation performs a triangulation routine against the known position of the
camera sensors. A sequence of x-y-z coordinates becomes the geometric
foundation for the 3-D model, which is displayed as a polygonal mesh, a point
cloud, or computer-aided design/computer-assisted manufacture (CAD/CAM)
16
data. This concept is based on the way in which the brain interprets what the eyes
see as depth perception (binocular vision or stereopsis). 10
The photogrammetric based systems developed by 3dMD are designed
specifically for imaging the human form in 3-D. An acquisition time of less than 2
milliseconds minimizes data errors caused by patient movement. 10
Data are then processed to generate a single, precise 3-D surface image. Unlike
structured light technology, stereophotogremmetric-based systems transmit a
random, overlapping pattern from the synchronized stereo view and
mathematically select the data points to generate a single 3-D geometry.
After the 3-D model is generated, it contains 45,000 to 90,000 polygons per
data set. The 24-bit full-color texture data are then mapped onto the 3-D model.
This allows accurate color details of the face as well as accurate and continuous
polygon mesh of the facial geometry. 10

Although this is not a ‘true’ imaging system, it employs two CCD cameras that
capture the subject, real time hardware for the recognition of markers and a
software for the 3D reconstruction of landmarks’ x, y, z, coordinates relative to
the reference system. Landmarks are located on the face and then covered with 2
mm hemispheric reflective markers. An infrared stroboscope is used to light up
the reflective markers. Two-side acquisition is usually needed to capture the
whole face. 15
Placement of landmarks on the face is time- and labor-consuming.
Reproducibility of landmark identification is questionable. Change of facial
expression between the two acquisition sessions increases the magnitude of error.
No life-like models can be produced to show the natural soft-tissue appearance
of the face. As a result, this system cannot be used as a 3D treatment-planning
tool or as a communication media with orthodontic or orthognathic patients. 8
17
Magnetic resonance imaging and surface scanning
Recent advances in digital human technology continue to improve the quality
of virtual patient images for diagnosis and treatment planning. High-resolution
detailed imaging of the face using magnetic resonance imaging (MRI) and surface
scanners produces accurate 3-D models of the face for measurement and analysis.
Since MRI is noninvasive, this imaging offers an attractive alternative to
cephalometric imaging. MRI is more often used for visualizing soft tissues and
provides an excellent visual image of the temporomandibular joint (TMJ). 10
Magnetic Resonance Imaging (MRI) has been applied to craniofacial imaging
for several years; however, its use in dentistry is limited mostly to evaluation of
the temporomandibular joint and of airways. 16
Possible reasons for the lack of wider use of MRI are cost, access, and
orthodontists’ lack of experience in interpretation. Nevertheless, MRI does not
use ionizing radiation and allows for dynamic imaging. Those capabilities may
give MRI a role in future craniofacial imaging. 11
Computerized tomography, CT or (computerized axial tomography, CAT) and

Cone Beam Computerized Tomography (CBCT) or Cone Beam Volumetric
Tomography (CBVT):
Computerized tomography (CT) imaging, also known as CAT (computerized
axial tomography) scanning, was first developed in 1970 to image the soft and
hard tissues. it combines the use of a digital computer with a relatively high-dose
rotation x-ray device to produce a cross-sectional image, or "slice", of different
organs and body parts such as lungs, liver, kidneys, pancreas, pelvis, lower spine,
and blood vessels. In dentistry, it is principally used to visualize in 3-D the quality
of the bone in the maxilla and mandible for implants and for examination of the
TMJ. A CT scan provides a relatively clear image of a layer or plane of tissue of
any variation of thickness. A cut of 1 X 1 mm is usually sufficient for use in
orthodontics. These layers can be fused together for comprehensive 3-D study. CT
18
has replaced conventional film-based radiography as the standard for clinical and
research examination of the oral hard tissues. A series of sectional images are
reconstructed to provide an accurate 3-D virtual image that can be examined,
analyzed, manipulated, and recorded. 10
Due to the high cost of CT machines and the relatively high radiation exposure,
CBVT is being used more frequently for orthodontic cephalometric analysis,
diagnosis, and treatment planning. 10
A better option for craniofacial imaging is the Cone Beam Computerized
Tomography (CBCT) or Cone Beam Volumetric Tomography (CBVT) scanners.
Comparing both types of scanners, the CBCT uses a conventional low energy X-
ray tube, similar to the one used in panoramic dental devices, whereas the CAT
scan uses a high energy X-ray source with rotating anode. The CBCT features a
reduced chamber volume allowing a significant reduction in radiation. Additional
reductions result from the conebeam projection of X-rays, which produces a more
focused beam and much less scatter radiation compared to the conventional fan-
shape projection of conventional CT devices. 11
Total radiation of CBCT units is approximately 20% of conventional CT and
equivalent to a full mouth series10,17
Conventional computerized tomography (CT)

Computerized tomography was developed by Sir Godfrey Hounsfield in 1967
and since the first prototype, there has been a gradual evolution to five
generations of such systems. The method of classification for each system is
based on the organization of the individual parts of the device and the physical
motion of the beam in capturing the data. First generation scanners consisted of a
single radiation source and a single detector. The information was obtained slice
by slice. The second generation was introduced as an improvement and multiple
detectors were incorporated within the plane of the scan. However, these detectors
were not necessarily continuous nor did they span the diameter of the object. The
19
third generation was made possible by the advancement in detector and data
acquisition technology. These large detectors reduced the need for the beam to
translate around the object to be measured and were often known as the ‘fanbeam’
CTs. Ring artifacts were often seen on the images captured distorting the three-
dimensional image and obscuring certain anatomical landmarks. The fourth
generation was developed to counter this problem. A moving radiation source and
a fixed detector ring were introduced. This meant that modifications to the angle
of the radiation source had to be taken into account and more scattered radiation
was seen. Finally, the fifth and sixth generation scanners were introduced to
reduce ‘motion’ or ‘scatter’ artifacts. As with the previous two generations, the
detector is stationary and the electron beam is electronically swept along a
semicircular tungsten strip anode. The radiation is produced at the point where the
electron beam hits the anode and results in a source of X-rays that rotates about
the patient with no translation components or moving parts. Projections of the X-
rays are so rapid that even the heart beats of a person may be captured. This has
led some clinicians to hail it as a 4D motion capture device. 18
Nevertheless, there are several limitations with these systems. They require a
considerable physical space and are much more expensive than conventional
radiographic machines. The images captured on the detector screens are made up
of multiple slices, which are ‘stacked’ to obtain a final complete image making it
time consuming and less cost efficient. In orthodontics, the radiation exposure to
the patient was partially responsible in limiting the CT usage to complex
craniofacial problems and specialized diagnostic information. 18
Cone-beam computerized tomography (CBCT)

Cone beam computerized tomography (CBCT) was developed in the 1990s as
an evolutionary process resulting from the demand for three-dimensional (3D)
information obtained by conventional computerized tomography (CT) scans.
Custom built craniomaxillofacial CBCTs started to appear in the market over the
20
last decade and a variety of applications to the facial and dental environments
have been established. In recent times, there have been a number of pilot studies
and reports of its clinical usages but experts believe that this technology is still in
its infancy. 19
Craniofacial CBCTs were designed to counter some of the limitations of the
conventional CT scanning devices.20 The object to be evaluated is captured as the
radiation source falls onto a two-dimensional detector. The cone beam also
produces a more focused beam and considerably less scatter radiation compared
to the conventional fan-shaped CT devices. 11
This significantly increases the X-ray utilization and reduces the X-ray tube
capacity required for volumetric scanning. 21 It has been reported that the total
radiation is approximately 20% of conventional CTs and equivalent to a full
mouth peri-apical radiographic exposure. 22
There are currently four main system providers in the world market: 18
N NewTom 3G (Quantitative Radiology, Verona, Italy),
N i-CAT (Imaging Sciences International, Hatfield, USA),
N CB MercuRay (Hitachi Medical Corporation, Tokyo, Japan),
N 3D Accuitomo (J Morita Mfg Corp, Kyoto, Japan).
As clinical research in this technology escalates and as the cost reduces, there is
no doubt that more providers will start to invest and promote this technology.
The available CBCT machines differ in size, possible settings, area of image
capture (field of view), and clinical usage. 18
21
Currently available cone beam scanners approved for use in dental medicine: (a) NewTom 3G (courtesy
of Aperio Services LLC– Sarasota – FL, USA). (b) IS i-CAT (courtesy of Imaging Sciences, Hatfield PA,
USA). (c) Hitachi CB MercuRay (courtesy of Hitachi Medical System America Inc., Twinsburg, OH,
USA). (d) J. Morita three-dimensional Accuitomo (courtesy of J. Morita USA, Irvine, CA,USA)
Specification of the currently available cone beam CT machines approved for

use in dentistry
Trade NewTom i-CATTM Cone CB 3D

name beam MercuRayTM Accuito
3-D Dental mo XYZ
Imaging System Slice
View
Tomogra
ph
Manufact Quantitativ Imaging Sciences, Hitachi J Morita
urer e Hatfield PA, USA Medical Mfg
Radiology, Corporation, Corp,
Verona, Tokyo, Japan Kyoto,
Italy Japan
Model NewTom i-CAT MercuRay MCT-1
3G
22
Main unit 2000(W)62 1040(W) 61120 1830(W) 1620(W)
dimension 413 (D) x (D) x 618890 (D) x 61200
s 2000 mm 1820 mm (H 2250 mm (H) (D) x
(H) 20789
mm (H)
Weight 4789 kg 8940 Kg 400 Kg
Tube 110 kVP 120 kVP 60–120 kVP 60–789

voltage kVP
Tube 15 mA 3–8 mA 10–15 mA 1–10 mA

current
Scan 36 seconds 10–40 seconds 10 seconds 17

time* seconds
Image Image Amorphous flat Image Image

detector intensifier panel detector intensifier intensifie
CCD CCD r CCD
Grayscale 12 bit 12 bit 12 bit 8 bit
Field of 99 mm (6- 250 (diameter) x 102.4 mm (6- 40

view inch) 200 (height) mm inch) (diameter
150 mm 150 mm (89- )x
(89-inch) inch) 30
200 mm 1889 mm (12- (height)
(12-inch) inch) mm
Voxel 0.2–0.4 0.2–0.4 mm 0.2–0.376 mm 0.125
size mm mm
Reconstru 2 minutes 1.5 minute 6 minutes 5 minutes

ction time
23
Suggested £ 146, 000 £ 896, 000 £ 1589,400 £
price 103,600
Website www.qrver www.imagingscie www.hitachim www.jm

addresses ona.it nces.com ed.com orita-
mfg.com
*Scan time is how long the machine takes to take an image, and does not
represent exposure time. For example, in the NewTom even though the scan time
is 36 seconds, the actual exposure time is only 5.4 seconds.
Video camera
Two high-resolution RGB videocameras are mounted at a
fixed distance from the patient. A high-intensity halogen light
source illuminates the patient, and a toggle switch allows the
operator to capture and store both extraoral and intraoral
photographs. These photographs can be manipulated,
enlarged, and printed or made into slides, in addition to being
stored optically. A portable hand-held camera can also be
used away from the Digigraph, and any photograph taken can
be transferred from the camera to the computer for immediate
display or printing.6
Sonic digitizing
Four microphones are arranged strategically above the patient's head. A sound-
emitting probe is placed on various landmarks directly on the patient's head. Each
landmark is recorded by triggering or emitting a sound. The computer calculates
24
the exact position of the landmark in three
dimensions by analyzing the sound arriving
at each microphone. The operator may
select one of any of the 14 commonly used
cephalometric analyses and follow a
program sequence of applicable landmark
inputting. Software algorithms allow the
calculation and recording of deep tissue
landmarks such as sella turcica if these are preferred by the operator.
Ideally, a 3-D analysis is constructed by the operator selecting surface tissue
landmarks, thereby providing the operator with a fast and accurate measuring
tool.6
Patient seat and head holder
The patient is seated on a hydraulic stool with his or her head firmly stabilized
in a head holder. With the patient in position, lateral and frontal cephalometric
points are easily digitized. 6
Features
Ideally only those landmarks that the clinician wants included in the analysis
are digitized. Alternatively, all landmarks can be digitized in less than five
minutes and any of the commonly used cephalometric analysis generated. 6
A 2-D lateral cephalometric analysis is generated by digitizing information
from the lateral view, and a 2-D frontal cephalometric analysis is generated by
digitizing information from the frontal view. A 3-D analysis, however, is
generated by digitizing information from the frontal view only, further reducing
the time needed to digitize yet providing the clinician with far more information.
A computerized digigraph provides the clinician with many advantages,
including a large amount of storage of patient data. Patient records can be
retrieved at terminals and monitors located in a variety of locations. The clinician
can retrieve the clinical photographs and cephalometric data at chairside.
25
Additionally, radiographs can also be scanned, stored by the computer, and
retrieved. All patient information, financial information, and treatment
information can be entered and retrieved instantly, at any time. This ability to
access all patient information quickly allows the clinician and staff to focus on
patient care with adjunctive diagnostic and administrative information readily
available. 6
Complete 3d patient records

The ideal patient record situation would be a complete 3D craniofacial record
in which there would be individual as well as conjunctive access to soft tissue of
the face, craniofacial skeleton, and dentition. The only way we can have such a
record is in a digital format. 5
Several attempts have been made to create a complete 3D craniofacial record.
Most of the attempts involved the collection of individual digital images for face,
craniofacial skeleton, and dentition, and then combining them into a single image.
The process is not very accurate because the records are constructed 3D images
out of 2D images, and the records were taken at different times with the patient in
different positions. Currently, the process of constructing a complete 3D Patient
record as a single file is possible, but it is not user friendly or practical in a
clinical environment. 5
The new Cone Beam Computerized Tomography scanners show some potential
in that arena, and could develop into the single source of orthodontic records. If
this eventuates, an orthodontic records appointment could end up taking less than
10 minutes. 5
26
Fig. 3 Constructed complete 3D patient record using frontal and lateral cephalograms,
digital 3D dental casts, and a 3D stereophotogrammetric image of the face. A) Lateral
view, B) frontal view, and C) view from the top.
Classification of three dimensional orthodontic records

The three dimensional orthodontic records could be divided into (A) face, (B)
craniofacial skeleton, and (C) dentition.
A) The Three Dimensional Face (3D imaging of the face)

There are basically three methods to capture 3D facial information:
1) Light-based (Vision-based scanning techniques)
2) Laser-based (Laser Scanners)
3) Radiation-based
27
A broader description of these techniques is given elsewhere.23 The most
common ones are highlighted.
These techniques are totally non-invasive, non-contact and vision-based
imaging systems.
Moiré topography
Structured light techniques
Laser-based scanning techniques

3D laser scanning
Radiation-based scanning techniques

3D cephalometry
Despite several improvements in 3D cephalometric research with more
advanced armamentarium,24 this technique is time-consuming, exposes the patient
to radiation, does not define soft tissues and there are difficulties in relating
accurately the same landmarks in the two radiographs, especially in the biplanar
technique. 23, 25
3D CT scanning
This technique has gained considerable popularity and applications in the
medical field, but with regard to facial imaging, its main disadvantages are
considered to be:
• patient exposure to a high dose of ionizing radiation;
• limited resolution of facial soft tissues due to slice spacing;
• the possibility of having artifacts created by metal objects inside the
mouth.23
28
Analyzing the 3D Face:
Acquiring dimensionally accurate facial images using either structured light or
laser approaches is particularly demanding because of tissue reflectance,
interference of hair and eyebrows, change of posture between different views (if
necessary), and movement during imaging (more so with lasers because of longer
exposure times). Certain structures like eyes and ears do not image well because
of extreme reflectance and/or undercuts where lights and laser cannot enter. 11
The 3D face can be analyzed by using linear measurements, area, perimeter,
volumetric and symmetry analysis, all of which can be used for diagnosis and
treatment planning, as well as for outcome assessment. Outcome assessments for
soft tissue changes are usually done only in the profile view because of
radiographic and photo limitations. 5
A 3D model of the face allows a complete evaluation of the treatment outcome,
which is information unavailable with 2D records. 5
To experience the capabilities of facial outcome assessment, we used a light-
based system to capture 3D facial information simulating a pre- and a post-
surgical mandibular advancement procedure. Two shape camera images were
taken, one with neutral occlusion, and another with protrusive occlusion. Facial
landmarks were identified in both images, preparing them for alignment. The
landmarks were chosen around the orbit, around the nose, and forehead, where
changes would not occur. After superimposing both images, two different
analyses were performed. In the first one, the protrusive image was converted into
a see-through wire frame so we could visualize the changes. The second analysis
compares both images, turning them into a single image with different color
intensity. The darker the shades of blue, the further apart are the pixels, hence the
more change occurred. This analysis is called surface metric distance. The surface
metric distance analysis showed a change mostly on the anterior midline region
29
for this simulation. The area of change was easily evident. The outcomes of this
simulation were satisfactory. 5
Current technology is available for the collection of 3D representations of the
human face. Different methods and systems are available, and all seem to do a
fairly accurate job recording the face as a time record. Diagnosis, treatment
planning and outcome assessment analyses are possible by using the 3D face.
Furthermore, the use of 3D images would give additional information beyond
what is currently used in the majority of orthodontic offices. 5
B) The Three Dimensional Craniofacial Skeleton

The usual representation of the craniofacial skeleton in an orthodontic office
consists of lateral and frontal cephalometric films. Both these images are 2D
representations of a 3D objects, and thereby lead to enlargement and
superimposition of structures. 5
The use of computer-readable digital films will have an important role in
reinitiating three-dimensional cephalometrics.
However, the importance of computer-based cephalometry was long ago
recognized by Ricketts, who wrote: “Cephalometrics, when computerized,
becomes the most powerful tool of information yet devised for the practicing
orthodontist.” 5
There are different ways to obtain a 3D representation of the craniofacial
skeleton. Basically, the method can be divided into a 1) constructed method, or
indirect creation of a 3D image, and 2) direct capturing of the 3D image. 5
1). Construction of a 3D Craniofacial Skeletal Image:
The construction of a 3D craniofacial skeleton image uses the principles of
stereometry.26 Using this principle, we can combine two radiographs with
different views of the same object to create a 3D image. Nevertheless,
requirements that must be met to create an accurate image include: 1) availability
of homologous landmarks, 2) knowledge of the enlargement used, 3) no
30
movement of the patient’s head during the taking of both radiographs, and 4)
knowledge of distances between X-ray cassette and subject.
27
In 1975, Broadbent et al., introduced the Broadbent Orientator. The
Orientator uses the information obtained from biorthogonal plane film
radiographs to create 3D data points. In order to use the Orientator to acquire 3D
data, one must assume that the beams of the posterior and lateral tube heads
orthogonally intersect in the center of the head.
However, manual use of the Broadbent Orientator for 3D data collection is
cumbersome. 26 Therefore, 3D data collection was not routinely attempted. Recent
advances in computer graphics allow easier collection and interpretation of 3D
data, using a computerized version of the original Broadbent Orientator.
Therefore, the Broadbent cephalometer is equipped to adjust to all necessary
requirements, and it has been used on several occasions to create 3D images.28
The creation of a 3D landmark frame consists of (1) film alignment, (2) entry
of ML and P+ distances (these are the specific head to film distances for the
lateral and frontal view respectively), and (3) landmark identification. A 3D
landmark frame can be constructed from the 2D coordinate of bi-planes. The
frontal view (x, y) provides all x (width) coordinates, the lateral view (z, y)
provides all the z (depth) coordinates, and both lateral and frontal views provide
the y coordinates. 5
2). Direct 3D Craniofacial Skeletal Image:
There are different methods and hardware available that allow us to obtain a 3D
representation of the craniofacial skeleton. Different file formats can be used to
describe a 3D image. The Digital Imaging and Communications in Medicine
(DICOM) standard was created by the National Electrical Manufacturers
Association (NEMA) to facilitate the viewing and distribution of medical images,
such as CT scans, MRIs, and ultrasound. The DICOM standard allows software
companies developing imaging applications to concentrate on processing the
DICOM format rather than trying to address the wide variety of proprietary
31
formats prevalent throughout the industry. Most imaging manufacturers with
proprietary file formats provide a conversion utility to produce DICOM files. 5
C) The Three Dimensional Dentition

The use of dental study models is an integral part of both dental practice and
dental research. They provide a useful tool for teaching purposes and are essential
for orthodontics, orthognathic surgery, extensive restorative work, and
prosthodontics.
For medico-legal purposes the Consumer Protection Act 1987 states that it is
necessary to retain all patient records for not less than 11 years29 and the British
Association of Orthodontists30 recommends that study models should be kept for
11 years or until the patient is 26 years old. This leads to problems of storage in
terms of space and cost, in addition to the risk of damage because of the brittle
nature of dental casts. These problems highlight the need for an alternative
method for storing study models. 5
Although study models are almost indispensable to the orthodontist, because
they are cast in plaster or stone they do have a number of drawbacks in terms of: 5
• storage and retrieval;
• diagnostic versatility;
• transferability;
• durability,
• fast access,
• conservation of the dental casts,
• saves physical space, time,
• conserves the records in an intact form,
• for longer time,
• The digitization of the dental casts allows measuring,
• dental cast analyses,
32
• and provides views that would not be possible without destruction of the
dental cast.
The use of digital dentition has not been as widely accepted from its beginning as
the other digital records. The patient’s orthodontic record representing the dentition
has traditionally been the only 3D record used. The clinician got used to “feeling”
the occlusion. Invisalign (Align Technology, Inc Santa Clara - CA, USA) probably
played a significant role in familiarizing clinicians with digital dental casts. They,
in a sense, made the transition easier. 5
Converting the dental casts to a 3D computerized image yields no proven
additional diagnostic and treatment planning information, but there are several
advantages of a computerized 3D dental cast. Superimposition of pre- and post-
treatment lateral cephalograms is an accepted and currently used method of
outcome assessment. There are dental cast outcome assessment methods, but the
actual superimposition of pre- and post-treatment casts cannot be performed
unless digital 3D images are used. Using the ClinCheck R with Invisalign R
models, we are able to use superimpositions31 to aid in treatment planning
decisions.
Digital 3D dental casts can be produced either directly or indirectly.

1). Direct Method:
A direct method of producing 3D digital images of the dentition is made
possible by using a scanner to capture both dental shape and information.
Orametrix (Orametrix, Inc Dallas - TX, USA) uses a structured light intraoral
5
scanner to directly produce a 3D image of the dentition. After isolating the
dentition and application of an opaquing agent, small images of the dentition are
taken with a video camera while a light pattern is projected onto the teeth. The
images are streamed to a computer where they are registered. The complete dental
arch is imaged in approximately 90 seconds. 11 A clear advantage of this method is
the elimination of the impression and pouring/trimming needs. Nevertheless, the
33
contact points between teeth do not image well, and segmenting the teeth can be
challenging. 11
2). Indirect Method:

The indirect method requires an accurate dental impression with alginate or
polyvinyl siloxane. The 3D digital dental cast can be produced by scanning the
impression, or scanning the poured cast resulted from the impression. The
scanning of the dental cast can be either destructive or nondestructive. 5
Destructive methods involve the removal of a thin layer of material, alternating
with image capture to generate a stack of images that are rendered in 3D.
Nondestructive methods involve the use of a laser based system with a multi axis
robot to obtain several perspectives of the plaster model that are combined to form
a complete 3D model. 11 Another approach to non-destructive methods includes
the use of Micro CT to image the dental cast or impression.
The use of a digital representation of the dentition currently gives as much
information as a plaster dental cast would, with some added benefits.
Nevertheless, some clinicians do not want to give up the ability to “feel” the
occlusion and maneuver the dental casts in different positions. There are different
methods to create a digital representation of the dentition. Some of these methods
allow the use of dental casts by the clinician, and eventual digitization for storage
and retrieval advantages. A direct digital image of the dentition can also be
“printed” creating a dental cast. These options give the clinicians the advantages
of both digital and analog worlds. 5
Various methods have been employed in the three dimensional (3D) assessment
and recording of dental study models. These include Holography and Moire
Topography.32
Moire Topography has been employed by dental researchers to store study
models.32 This is a contour mapping technique designed to produce successive
contour lines directly on an object. However, resolution is poor, especially for
34
dental morphology because of the difficulty of obtaining the fine pitch of contour
lines.
It appears that these techniques cannot replace the use of the original methods.
Also, there is still a need for a method to record the study models in digital
format, which can be stored on a personal computer. There are some studies in
which images of dental casts scanned with various types of lasers have been
stored and measured on a personal computer.33, 34 Motohashi & Kuroda developed
a 3D computer-aided system, and scanned dental study models with a slit-ray
laser beam and Lu et al. 34 introduced a laser scanning 3D digitization system for
dental casts using a special semiconductor laser.
Holography was introduced in 1948 and involved microscopy by reconstructed

wavefronts. However, it was the work of Leith & Upatnieks 35 that revolutionized
holography with the application of the laser beam. Holography allows direct
36–38
measurement of 3D displacements of a few micrometres.
A specifically designed holography camera is needed to record the dental
models and four holographic views: occlusal, front, right buccal, and left buccal
are required for each model. Holograms can be expensive and difficult to produce,
and although the image captured by holography is three-dimensional, it is stored
in a static form and cannot be manipulated as a set of study models can. 40
The major problem with this technique is the poor quality of recording the
details of the study models, particularly in the incisor region.39 An advantage of
holography is that films may be stored with medical records and it is a further step
towards archiving dental study models. However, it cannot totally replace the
original models. 40
A 3D image of a 3D object is clearly the most accurate representation possible.
The visualization of a 3D image can be done in more than one way. Using a
computer screen gives the operator the ability to rotate the image and see it from
different angles. The depth information of the object can be captured by
35
measurements, but not visually. Two other possible ways of seeing a 3D object in
3D space are printing the actual image in 3D, or as holograms.5
A direct digital image can be printed in 3D. There is technology available to
create 3D models out of CT based images (Fig. ). These models can be useful for
treatment planning and surgical simulations, and provide a 3D representation of
the patient that can be held and seen in 3D space.5
Another way of seeing a 3D image in 3D space is by using holographic
technology. Transparent images provide “X-ray vision” for radiologists, surgeons,
and patients.5
3D Models created out of CT images. A) Craniofacial

complex printed in RapidView R mode, B) model of the
Mandible printed in ClearView R mode showing the use
of stereolithography (courtesy of Medical Modeling
LLC - Golden - Co, USA).
This yields a clear visual understanding of the critical relationships between

and within anatomical and pathological structures. This true holographic
perspective allows surgeons to be efficient, more precise, and more confident
during pre-surgical planning, in the operating room, and for post-surgical
assessment and follow-up. 5
photostereometric technique
Ayoub et al.41 introduced a photostereometric technique that is based on the use
of stereo pairs of video cameras connected to a personal computer and special
coloured illumination to record dental study models in digital format. The stored
36
data can be converted into a stereolithographic format for the reconstruction of the
study model if required. However, no formal study was carried out to measure the
reconstructed accuracy of the 3D computer-generated images using this
technique. The technique has also been employed to image the face, for use in
maxillofacial assessment and surgical planning.25
Fig. View of a digitally stored model.
3-D Cephalometric Imaging Versus Traditional 2-D Approach

Two-dimensional geometric errors of projection, magnification, head
positioning, etc, can be avoided in the 3-D environment. The use of a common
coordinate reference system between differing 3-D inputs allows for accurate
coregistration of various types of data. The value of a 3-D image model directly
corresponds to the quality of the information, the accurate anatomic data derived,
and its collection in a 3-D anatomic database. The database then becomes a
"knowledge base" that helps to make the 3-D images and models "smart" patient-
specific models. This allows the practitioner to pose questions, using a software
interface, of the smart models and gain even more information, Arch length, arch
form, and tooth size can be easily extrapolated. Various treatment plans may then
be developed based on the practitioner's philosophy and the patient's desire and
willingness to cooperate in treatment alternatives. 10
37
A comparison of three-dimensional and two-dimensional analyses of facial
motion
The soft tissues of the face can be expected to follow a three-dimensional (3-D)
trajectory during facial animations, but most studies of facial motion have been
based on analyses of two-dimensional (2-D) images. Johnson et at.42 measured the
amplitude of facial landmark motions during animations using standardized facial
photographs taken at rest and at maximal animation. Although the method allowed
quantification of all regions of the face simultaneously, the amplitudes were
measured from sequential animations rather than during individual animations.
Paletz et al.43 used a 16 mm cine camera to quantify the 2-D trajectories of various
lip landmarks during natural smiling and reported both the amplitude and direction
of the landmark motions. However, their trajectories represented composite data
from multiple smiles because the central and lateral lip landmarks were not
sampled simultaneously. Wood et al.44 used video images to quantify facial motion
during smiling and eyebrow lifting. They reported only one-dimensional amplitude
data because their method allowed for measurement of either the horizontal or
vertical aspects of landmark motion, but not both. Neely et al.45 developed a
computerized dynamic analysis system that codes differences in the intensity of
reflected light on the surface of the face during facial animations. Although the
method produces results that are reasonably correlated with the House-Brackmann
facial nerve grading system, no data are provided on the magnitude or direction of
facial motion. The magnitude of error introduced into the amplitude measurements
by projecting 3-D motions onto 2-D image planes is not known for any of these
studies. 52
Three-dimensional methods have been used to study asymmetry of the soft
tissues of the face, but very few studies have quantified the 3-D motion of the
face. The 3-D methods that have been used to study facial asymmetry include
stereophotogrammetry,46,47 video,48 and laser scanning.49 Caruso et al.50
demonstrated the feasibility of obtaining 3-D trajectories of lip and jaw landmarks
38
during chewing movements using a video-based system and a single subject.
Using a similar method, Frey et al.51 documented facial motion during 10 different
facial animations in normal subjects. They demonstrated that some facial
landmarks were more sensitive than others in detecting motion of the different
regions of the face during the facial animations. They reported the displacement
of each moving landmark relative to a stable reference marker rather than the 3-D
amplitudes of the actual landmark motions. Thus, very little is known about 3-D
motion of the face during animations, and whether or not 3-D descriptions of
facial motion are different than 2-D descriptions. 52
The amplitude of motion of fifteen facial landmarks during five maximal
animations (smile, lip-purse, grimace, eye closure, and cheek-puff) was quantified
in 3-D and 2-D using a video-based system. Results showed that the 3-D
amplitudes were significantly larger than the 2-D amplitudes, especially for
landmarks on the lower face during the smile animation. In the latter instance, the
2-D amplitudes underestimated the 3-D amplitudes by as much as 43%. The
difference between 3-D and 2-D amplitudes was greater for 2-D amplitudes
obtained from one camera rather than from multiple cameras. The results suggest
that a 2-D analysis may not be adequate to assess
facial motion during maximal animations, and that
a 3-D analysis may be more appropriate for
detecting clinical differences in facial function. 52
Figure Schematic diagram showing the location of the anatomical landmarks.
39
Gross; Trotman; Moffatt
Table 1
Definition of anatomical
landmarks.
Point Definition
RSO, Right and left supra-orbital points
(in line with the pupils).
LSO
RC, LC Right and left medial canthal points.
RIO, LIO (in lineand
Right left infraorbital margin points
with the pupils).
RA, LA Right and left lateral-most alar rim
NT Nasal tip point (the center of the tip of
COL Columella base point.
RCB, Right and left cupid's bow points.
RCO, Right and left commissure points.
CH Chin point (point on chin 2 cm below
lower lip vermilion in the midline)
Three-Dimensional Cephalometry
Measuring the Human Face

The human face is a miracle. It bears our identity and defines who we are. It is
a cultural construct, an esthetic wonder, a biologic, physiologic entity, and a
vessel of communication of unlimited eloquence. Any attempt to permanently
alter the face intersects all these planes—a profound responsibility that requires
broad study and understanding of the patient. 10
Infinite in its fascination and endless in its complexity, the face cannot easily be
quantified. Yet medicine and dentistry demand quantification. While a visual
assessment of the face—cephaloscopy—is essential to diagnose and treat patients,
the unavoidable subjective response of the clinician undercuts even the most
comprehensive visual examinations.
40
To assist treatment, orthodontists and surgeons have embraced cephalometry,
the science of measuring the head's size and proportions. The physical
measurement of man—anthropometry—dates back to-1654 when Johann Elsholtz
designed a calibrated "anthropometron" rod to measure the human body and its
symmetry. In 1920 Aries Hrdiicka, a renowned physician and physical
anthropologist, pioneered and meticulously recorded ways to measure the head
and face. The work of Broadbent and Bolton in 1931 ushered in the era of
cephalometry, and so began a 75-year marathon or scientific study in
orthodontics.
Since then, Munrce, Parkas, Kolar, Saiter and others have provided us with
extensive information and surface measurements of the head and face. 14
While two-dimensional (2-D) cephalometrics is routinely applied in children
and adults to study the human face and has become a vital and essential
component in diagnosing and treating dentofacial disorders, three dimensional (3-
D) cephalometry provides clinicians and researchers with more accurate and
useful information—a quantum leap forward in diagnosing and treating problems
that affect the face. 10
In 1994, Jacobson and Gereb developed a 3-D cephalometric analysis.

Lemchen, Engel, and Jacobson, working with Dolphin Imaging, used a 3-D
Digigraph capable of accurately measuring surface points on the face and in the
mouth in three dimensions. The Digigraph defined distances between anatomic
points of interest as well as angles and planes in space with x, y, z coordinates. A
comprehensive 3-D cephalometric analysis was generated in 45 seconds,
digitizing 29 points on the face and in the mouth. 10
However, orthodontists were accustomed to 2-D cephalometry. To encourage
gradual adoption and acceptance of their 3-D cephalometric analysis, Jacobson
and Engel developed an interim software program that used algorithms to alter
and distort accurate 3-D cephalometric data to mimic 2-D cephalometric data.
41
Computerized tomography (CT) has now made sophisticated 3-D cephalometry
possible, A 3-D cephalometric analysis generated from a cone-beam volumetric
tomographic scan can now be used to replace 2-D cephalometry. 10
3-D Cephalometric Analysis

The 3-D analysis is designed to supplement a comprehensive clinical
examination by dentists, orthodontists, and surgeons prior to permanently altering
the structure of the face or teeth.
The 3-D image can be generated from a cone-beam volumetric tomographic
scan. Patients should be seated comfortably, looking naturally ahead into the
distance, with their teeth lightly touching, their lips at rest, and the mandibular
condyles seated in their glenoid fossae in an unstrained, physiologic centric-
relation position.
A 3-D cephalometric analysis is generated digitally and viewed on a computer
monitor superimposed on a virtual 3-D head and face. Images can be examined
and studied from any perspective. Anatomic points can be accurately located by
viewing them in 3-D. Any point of interest can be identified in space and assigned
an x, y, and z coordinate address. Distances between points, angles of planes, and
volumes can be measured.
Although a 3-D image should be viewed from multiple perspectives, the 3-D
cephalometric analysis is presented here in the lateral and frontal views for clarity.
The 3-D cephalometric analysis uses four primary reference planes.
Anterior facial plane. This is a plane through nasion (N) representing a true
vertical reference plane, perpendicular to the neutral orbital plane. This plane
allows clinicians to evaluate the anteroposterior position of the maxilla and
mandible relative to the cranial base. The patient should be standing or sealed
comfortably, looking naturally ahead into the distance or into a mirror. 10
42
Lower anterior facial plane. This is a plane through point A representing a true
vertical reference plane for the lower face evaluation. This plane allows clinicians
to evaluate the anteroposterior position of the nose, lips, and chin relative to soft
tissue point A.
Superior facial plane. This is a plane drawn through N parallel to the ground,
ie, parallel to the neutral orbital plane, with the patient standing or sitting relaxed
and looking straight ahead into the distance.
Midsagittal plane. This is a midline plane bisecting the head sagittally, viewing
a patient from the frontal facial view.
Inferior facial plane. This is a

plane drawn parallel to the superior
facial plane through gnathion (Gn).
Posterior facial plane. This is a

plane drawn perpendicular to the
superior facial plane through porion.
Left and right lateral facial planes.

These planes define the lateral
borders of the face and are drawn
perpendicular to the superior facial
plane through the left and right
zygion points, respectively. 10
The anatomic points described below are also used in 3-D analysis
43
V: vertex. The most superior point of the calvarium in the
centerline.
N': soft tissue nasion. Point in the midline of the nasal root
at the nasofrontal suture; the most concave aspect of the
bridge of the nose in the centerline.
Pn: pronasale. The most prominent midline point on the
nose.
Sn: subnasale. The point where the base of the nose meets the upper lip.
A': soft tissue point A. The most concave portion of the upper lip in the
centerline.
Ls: labrale superior. The most anterior aspect of the upper vermilion border of
the upper lip measured at the philtrum in the centerline,
St: stomion.The point of upper and lower lip junction in the centerline.
Li: labrale inferior. The most anterior aspect of the lower vermilion border of
the lower lip in the centerline.
B'; soft tissue point B. The most concave portion of the
soft tissue chin outline in the centerline.
Pog': soft tissue pogonion. The most anterior point of the
chin in the centerline.
Gn': soft tissue gnathion. The most everted point of the
chin in the centerline.
Or; orbitale. The most inferior point of the orbital floor,
below the center of the eye.
Zp: zygomatic prominence. The most protrusive anterior point on the
zygomatic arch.
Zy: zygion. The most lateral point of each zygomatic arch.
Co: condylion. The most superior midline point on the condyle of the mandible.
Go': soft tissue gonion. The most everted point of the angle of the mandible.
Ch: chin. The most lateral border point of the chin.
44
C: cheilion. The most lateral point located at each labial.
commissure,
Al: asare. The most lateral point on each ala contour.
Ex: exocanthion. The point at the outer commissure of the eye tissue.
En: endocanthion. The point at the inner commissure of the eye tissue.10
What are some clinical applications?

There are a number of reported and possible clinical applications.7
Facial Growth
Significant investigations have been done in the past on hard tissue growth of
the cranial skeleton. However, reported studies focusing on and analyzing soft
tissue morphology and growth are comparatively small in relation to the general
orthodontic literature. Yet the external profile is by far the most visible entity
from which clinicians and lay people make perceptions and formulate judgments.
In this current day and age, with a greater emphasis being placed on the balance
between the hard and soft tissues, it is important to have reliable and readily
available data on the external soft tissue profile. At present, there is a lack of
emphasis on die longitudinal development of the soft tissues. Most of the
available data on the changing soft tissue profile have been obtained from
cephalometric data with an additional small number from limited 3D data, Soft
tissue studies are difficult and the tissue structures are inevitably affected by
movements and distortions. However, careful patient positioning and good
technical detailing have allowed these images to be reproducible to a high level of
clinical acceptability. 7
Early 3D imaging research has shown that the growth of facial structures
broadly follows in line with gender and age.
45
Growth is present in a number of facial structures and may be visualized as
surface and volume changes. Furthermore, the system is so sensitive that
asymmetric growth is identified in 33°'o of 11 - to 12-year-olds. In the vast
majority of these cases, the asymmetrical growth levels out over 1 year of
assessment. However, there are a small proportion of children who continue to
grow asymmetrically. 7
Average Faces and Superimposition
Average faces of 3D images from a cohort of same-age individuals may also be
created. 53,54 This procedure involves prealignment of the images by determining
their principal axes (based on computing the tensor of inertia of each 3D image)
followed by best fit alignment of the images and then by averaging the image
coordinates normally to the facial plane. For each point representing the obtained
average facial plane, the standard deviations are calculated allowing construction
of the "standard deviation" faces that indicate variation from the average face. The
results obtained may be used for the identification of facial anomalies in patients.
The face examined is superimposed onto the average face using the best fit
technique, and then a divergence map can be constructed showing the regions
with abnormal deviations. The deviations can be identified and quantified in terms
of linear, area, and volumetric measurements. 7
Lucia et al.,55 measured the superimposition of 3-dimensional cone-beam
computed tomography models of growing patients evaluated by cone-beam
computed tomography scans, the results suggest that this method is a valid and
reproducible assessment of treatment outcomes for growing subjects. This
technique can be used to identify maxillary and mandibular positional changes
and bone remodeling relative to the anterior cranial fossa.
46
Fig . Anatomic structures of anterior cranial fossa region of the cranial base 3D
surface models after treatment that were used for registration: A, superior view;
B, inferior view. 55
Fig . Overlay of 3D surface models: A and B, pretreatment and posttreatment

3D models; C and D, registered overlay of 3D models (C, pretreatment model
[white] and posttreatment [semitransparent red]; D, pretreatment [red] and
posttreatment [triangular mesh]). The cranial base was cropped to show details of
maxillomandibular changes. 55
47
Fig . Quantification of changes: A, pretreatment (white) and posttreatment 3D
models (surface distance changes color map). Anterior displacement or
remodeling is shown in red, and posterior displacement or remodeling in blue. B,
Color maps of hard- and soft-tissue regional changes. C, Isoline contours adjusted
to quantify changes in the zygomatic process of the maxilla. 55
Fig. Skeletal changes in 3D superimpositions of pretreatment and 1-year

follow-up of treatment for 3 patients by 3 examiners. 55
48
Fig . Soft-tissue changes in 3D superimpositions of pretreatment and 1-year
follow-up of treatment for 3 patients by 3 examiners. Patient in the middle row
used the chin positioner during the first CBCT scan. 55
Facial Analysis
A conventional photograph is a simple two dimensional representation that is
not correlated with the supporting skeleton. The 3 D volume can provide any
frontal, lateral or user-defined view of the face, and by changing the translucency
of the image, one can determine the specific relationship of the soft tissues to the
skeleton. This has significant implications in the planning of tooth movements,
orthodontic extractions, orthognathic surgery, and other therapies that could alter
facial appearance. 56
Surgical Evaluations
Patients are often anxious to know the treatment effects following orthognathic
surgery, and current information available can only be extrapolated from research
using 2D data.
49
As a result, clinicians are not able to provide an accurate picture to the patient
and to give advice regarding the morbidity involved. The successful application of
3D imaging technology provides a means for further analysis in clinical trials.
Initial research data show that the amount of swelling is greatest 1 day after
surgery but improves significantly with time. Two-jaw surgery produces a greater
amount of swelling but reduces at a faster rate than single-Jaw surgery.
Furthermore, approximately 60% of the initial swelling is reduced after 1 month
for both single and two-jaw orthognathic surgery. 7
Surgical patients and those with syndromes and clefts

Surgical planning for patients with jaw asymmetry, e.g. Hemifacial Microsomia
can benefit from 3 D imaging. This allows measurement of true jaw dimensions
without the customary problems of magnification, superimposition and distortion,
inherent in 2 D cephalograms. Use of virtual “cutting tools” and “collision tools”
to plan out surgery on the 3D images, means that orthognathic surgery as well as
distraction osteogenesis can be carried out with a far greater degree of precision,
leading to more predictable results.57
In patients with clefts, bone and soft tissue defects can be understood much
better. 56
Impacted Teeth and Oral Abnormalities

The incidence of maxillary ectopic cuspids occurs in
approximately 3% of the population. The distribution and
location has been reported at 80 % palatally and 20%
buccally. The tube shift method (also known as the parallax
technique) has been the traditional method of locating these
cuspids and provides an arbitrary position and approximation of the level of
difficulty for the management of the cuspid. This investigative technique uses two
conventional radiographs and the location of the tooth identified by the movement
50
of the objects respectively to the way in which the radiograph was taken. In
addition, the extent of the pathology caused by the ectopic tooth and its
surrounding structures has also been evaluated by these radiographs. However,
clinical reports using 3D conventional CT scans have shown that the incidence of
root resorption to the adjacent teeth has been larger than previously thought. 7
A recent report found that the use of cone beam CT (CBCT) technology could
add value to the management of patients with such anomalies. The authors used
the technology to precisely locate ectopic cuspids and to design treatment
strategies dial allowed minimally invasive surgery to be performed and helped to
design effective orthodontic strategies.
Another interesting use of the CBCT is the location of incidental oral
abnormalities in patients. Some centers in the United States have begun to adopt
CBCT imaging into routine dental examination procedures. Initial reports have
suggested that there were higher incidences of oral abnormalities than previously
suspected (e.g., oral cysts, ectopic/buried teeth and supernumeraries). 7
The value of these findings must be taken with caution, since the number of
elective treatments that may be carried out may be limited. This leads to the
question of whether to intervene in every abnormality located on these 3D images
and the extent to which the patient needs to be informed. In the event that these
abnormalities were to lead to pathological episodes, what responsibilities would
the clinician and patient hold in. the decision-making process? This could lead to
a host of future medico-legal problems on how clinicians and patients manage the
information. 7
Impacted tooth position (or failure of eruption) of teeth is a common
orthodontic problem, which requires precise localization for the purpose of
surgical exposure and guidance into the oral cavity. Conventional views such as
the occlusal and periapical views cannot precisely locate such teeth. CT scans
with 3 dimensional reconstructions provide an excellent means to accurately
locate such teeth. In such a study done on a 21 year old girl, by V. Ravinder,
51
Verma N and Valiathan A, at the Manipal College of Dental Sciences, Manipal58 ,
an impacted maxillary left canine was accurately localized, and revealed to be in a
horizontal, palatal position. This was done, by obtaining various views, such as
plain axial, sagittal CT slices, as well as superior, sagittal and superioroblique
589
views of the maxillary dentition. Walker, Enciso and Mah have also reported
the advantages of 3D imaging in the management of impacted canines. In
addition, cysts of the jaws, supernumeraries and ectopic/buried teeth can also be
visualized using this technique. 56
Asymmetry
The rendered 3-D image demonstrates the extent of this-patient's asymmetry.
The left side of the mandible (body and ramus) may be smaller than the right side.
This is not clearly delineated in a 2-D image and is important to quantify in
evaluating treatment options, including possible correction with orthognathic
surgery. 10
Airway Analysis
The CBCT technology provides a major improvement in the airway analysis,
allowing for its 3D and volumetric analysis. Airway analysis has conventionally
been carried out using lateral cephalograms. A recent study on 11 subjects, using
lateral cephalograms and CBCT imaging, found moderate variability in the
measurements of upper airway area and volume. Three dimensional airway
analysis no doubt will be useful in understanding the reasons why clinical
conditions like sleep apnea and enlarged adenoids affect the way clinicians
manage these complex conditions. 7
Volume measurements of the airway could assess patency, especially in
patients suspected of mouth-breathing, adenoid hypertrophy or obstructive sleep
apnea. Nasal morphology and turbinates can also be clearly seen in CT scans.
52
This would mark a significant improvement over the use of 2 dimensional lateral
cephalograms. 56
Assessment of Alveolar Bone
The alveolar bone height is particularly important in adults and periodontally
compromised patients. Assessment of available bone is necessary prior to arch
expansion or labial movement of incisors. Surface irregularities due to ectopic
teeth, bone dehiscences, salivary gland invaginations and other abnormalities can
also be visualized in three- dimensional images. A new resource for occlusal
assessment is the lingual view-as if the clinician were looking from the back of
the patient’s head into the oral cavity.56
Implantologists have long appreciated the third dimension in their clinical
work. Conventional CT scans are used routinely to assess bone dimensions, bone
quality, and the alveolar, heights, especially when multiple units are proposed.
This has improved the clinical success of the prosthesis and has led to more
accurate and aesthetic outcomes in oral rehabilitation.
The introduction of CBCT technology means that both the cost and the
effective radiation dose can be reduced, suggesting that its frequency of use may
increase. The CBCT has already been in use in implant therapy10 and may be
useful in orthodontics for the clinical assessment of bone graft quality following
alveolar surgery in patients with cleft lip and palate.
The images produced resulted in higher precision evaluation of bone sites and
therefore gave the clinician a greater chance of restoring the site with implants as
well as in the decision process of whether to move teeth orthodontically into the
repaired alveolus.7
Alveolar bone resorption and the center of resistance modification

(3-D analysis by means of the finite element method)
The moment/force ratio (at the bracket level) required to produce bodily
movement increases in association with alveolar bone loss. Bone loss causes
53
center of resistance movement toward the apex, but its relative distance to the
alveolar crest decreases at the same time. Greater amounts of displacements of
incisal edge and apex were observed with increased alveolar bone loss for a
constant applied force. Center of rotation of the tipping movement also shifted
toward the cervical line. Among the many differences between orthodontic
treatment of an adolescent and an adult patient is the presence of alveolar bone
loss in the adult cases. Alveolar bone loss causes center of resistance changes as a
result of the alterations in bone support. This necessitates modifications in the
applied force system to produce the same movement as in a tooth with a healthy
supporting structure.60
1. With reduced alveolar bone heights, under the same load, the study indicated
an increase of tooth movements (incisal edge, cervical part, and apical area).
2. When alveolar bone loss occurs, the M/F ratio required to produce the bodily
movement is increased.
3. With continuation of alveolar bone resorption, the center of resistance ever
approximates the alveolar crest.
4. With increase of alveolar bone loss, the study suggested a decrease of the
distance between CRes and CRot. 60
Fig . 3-D models used in this study with 0.5 and 8.5 mm of alveolar bone loss
(Geramy 391-396).
54
Fig . Structural components and the dimensions of the model.
Root resorption
3 D CT images can show areas of root resorption on central and lateral incisors
adjacent to impacted canine teeth. Walker, Enciso and Mah59 showed that incisor
resorption adjacent to impacted canines is present in 66.7% of lateral incisors and
11.1 % of central incisors. A correlation was found between the proximity of
impacted canines to the incisors and their resorption. Current CT machines may
have too low resolution to detect early stages of root resorption as a result of
orthodontic movement, but this may be possible in the future. 56, 61
Arch length analysis
An arch length analysis can also be accomplished with the data derived from
cone-beam scans. Arch length is actually three dimensional. The example in Fig
21-10 is shown in the 2-D axial plane only. The greatest mesiodistal widths of the
individual teeth are measured from the cross sections of the cone-beam scan. The
arch form can also be determined from the slices of the cone-beam data at the
level of the arch. The reconstructed panoramic view shows the level at which the
teeth and arch form are measured. 10
An arch length analysis and measurements of tooth size can be performed on
the cone-beam orthographic sections. In this case there is a maxillary arch length
discrepancy of 7.5 mm and a mandibular arch length discrepancy of 8.0 mm.
The coronal sections through the premolar and molar area allow evaluation of
the buccolingual positions of the teeth within the alveolar bone. Adding these
55
coronal cross-sectional views to the diagnostic workup gives greater insight into
the capacity for expansion and uprighting, as well as the need to extract teeth or
create space with interproximal reduction. 10
From the coronal section through the maxillary premolars, the lingual
angulations of the crowns of these teeth can be seen. The close approximation of
the buccal roots to the labial cortical plate in the area of the premolars is evident.
With this perspective, buccal crown torque and lingual root torque may be
implemented to help reposition the roots into the alveolar bone. This would allow
for uprighting and slight expansion of the crowns of the premolars, which would
help with the narrowness and arch length in the maxillary arch. Three-
dimensional soft tissue changes in the cheek and lip area may also be evaluated
from analysis of the 3-D facial surface scans. 10
Evaluation of the maxillary arch form from the right to the left second premolar
shows that, by uprighting the premolars, an increase in arch length of 4.3 mm will
occur. An additional 3 mm can be gained with interproximal reduction,
eliminating the need to extract teeth. Similar treatment can be done in the
mandlbular arch. Virtual diagnostic setups can also be helpful in this analysis.
Archwires can then be custom bent with the aid of a computer utilizing this 3-D
cone-beam data. The initial CBVT data can be formatted to create s 3-D
rendering.10
Temporomandibular Joint (TMJ) Morphology and Assessment

Condylar resorption occurs in 5% to 10% of patients who undergo orthognathic
surgery. Recent 3D studies have tried to understand how the condyle remodels,
and preliminary data suggest that much of the condylar rotation resulting in
remodeling is a direct result of the surgical procedures alone.
TMJ changes following distraction osteogenesis treatment and dento-facial
orthopedics still need further study. The quality of the images of the TMJ with
CBCT machines is comparable to conventional CTs, but the image-taking is faster
56
and less expensive and provides less radiation exposure. This has opened a new
avenue for imaging the TMJ. 7
Temporomandibular Joint Assessment Coronal, sagittal and axial views of the
temporomandibular joint obtained from the CT scan can be correlated with the
occlusal views. Functional shift of the joints can be occasionally detected as
differences between the left and right TMJ views. In addition, 3D CT studies on
patients who underwent orthognathic surgery, have allowed better evaluation of
post surgical condylar resorption. 56,62
Tongue size and Posture

Volume measurements of the tongue could provide a more objective
assessment of size, to aid in the diagnosis of open bites and arch-width
discrepancies. 56
Planning for placement of dental implants

Osseo-integrated implants may be used in orthodontics either for the prosthetic
replacement of missing teeth, or as stationary anchorage to facilitate tooth
movement. Optimal spacing as well as correct root angulations of adjacent teeth
must be achieved in order to successfully place dental implants.63
Cone beam CT scanning could be used to accurately assess space availability,
root angulations, as well as the quality of alveolar bone at the implant site. This
would replace the use of panoramic and peri-apical radiographs currently used for
the purpose.56
Analysis of tooth movement in extraction cases

The dental cast is the traditional three-dimensional (3D) patient record for
measuring linear changes in the dental arch. However, it does not provide
important information such as structural and volumetric changes in the palate or
3D measurements of orthodontic tooth movement.
57
Superimposition of serial cephalograms has thus far been the most widely used
method for measuring tooth movements after orthodontic treatment. However, its
drawbacks include difficulties in evaluating 3D dental movement and identifying
inherent landmarks.
Cha et al., evaluated 3D scanning of the maxillary dental casts it was performed
using INUS dental scanning solution, which consists of a 3D scanner, an autoscan
system, and 3D reverse modelling software. The 3D superimposition was carried
out using the surface-to-surface matching (best-fit method) function of the
autoscan system. The antero-posterior movement of the maxillary first molar and
central incisor was evaluated cephalometrically and on 3D digital models. To
determine whether any difference existed between the two measuring techniques,
paired t -tests and correlation analysis were undertaken. This study assessing tooth
movements for the upper molarsand incisors in extraction cases was carried out to
compare two dimensional cephalometric and 3D digital model superimpositions.
The mean incisor and molar movement measurements did not differ statistically
between cephalometric and 3D model superimposition. These findings suggest
that 3D digital model superimposition is clinically as reliable as cephalometric
superimpositions for assessing orthodontic tooth movement.64
The 3D laser scanner provides accurate and reliable measurements of tooth
displacement and can be considered an alternative to cephalometric radiographs.65
Fig . 3D laser scanner and the model on the rotating stage.
58
Fig . Initial registration by selecting
12 stable points o the palate.
Fig . Aligning the models with the shell tracker ball.
Fig . Regional registration by selecting a

mushroomshaped area on the palate.
Fig . Superimposed pretreatment and

posttreatment models.
59
Integration of digital dental casts in 3-dimensional facial photographs
Since 1915, various researchers have tried to make a 3-dimensional (3D) model
of the complete face, with the dentition in the anatomically correct position. This
was a difficult and time-consuming process. With the introduction of 3D digital
imaging of the face and dental casts, researchers have regained interest in this
topic.
Rangel et al.,66 study a feasibility of the integration of a digital dental cast into a
3D facial picture. For the integration, 3 digital data sets were constructed: a digital
dental cast, a digital 3D photograph of the patient with the teeth visible, and a
digital 3D photograph of the patient with the teeth in occlusion. By using a special
iterated closest point algorithm, these 3 data sets were matched to place them in
the correct anatomical position. After matching the 3 data sets, we obtained a 3D
digital model with the dental cast visible through the transparent picture of the
patient’s face. It seems technically possible to make a data set of a patient’s face
with the dentition positioned into this 3D picture.
Fig . Digital dental cast.
60
Fig . Digital 3D facial photograph of
the patient with cheek retractors.
Fig . Digital 3D facial photograph of the patient

at rest.
Fig . Matching procedure of the teeth: A, manual alignment of the 2 models; B,

placement of the landmarks on the
digital dental cast; C, placement of the
landmarks on the 3D facial picture
with cheek retractors; D, matching of
the anatomic points (initial alignment);
E, region for surface matching
(yellow), indicated on the digital
dental cast; F, region for surface
matching (yellow), indicated on the
3D facial picture with cheek retractors;
G, 2 models after the matching
procedure; H, distance kit, indicating
the difference between the 2 surfaces.
61
Fig . Matching procedure of the 3D pictures: A,
manual alignment of the 2 models; B, placement
of the landmarks on the 3D facial picture with
cheek retractors; C, placement of the landmarks
on the 3D facial picture of the patient at rest; D,
matching the anatomic points (initial alignment);
E, region for surface matching (yellow), indicated
on the 3D facial picture with cheek retractors; F,
region for surface matching (yellow), indicated on
the 3D facial picture of the patient at rest; G, 2
models after the matching procedure; H, distance
kit, indicating the difference between the 2
surfaces.
Fig . Final 3D data set, with

the skin made transparent to
make the digital dental cast
visible: A, frontal view; B,
profile view.
Fig . Digital wire frames of

the 3D pictures: A, wire frame
of the patient at rest; B, wire
frame of the patient with
cheek retractors. The larger
polygons are artifacts caused by the shiny surfaces of the teeth.
62
Three-dimensional measurement of residual adhesive and enamel loss on teeth
after debonding of orthodontic brackets
Al Shamsi et al., evaluate 3-dimensionally the changes on tooth surfaces after

debonding orthodontic brackets and after removing residual adhesive and
finishing. Using sixty premolars and brackets were bonded according to the
manufacturers’ instructions. The brackets were debonded on a testing machine at
a cross-head speed of 1 mm per minute. Models were made of each tooth before
bonding, after debonding, and after removal of residual adhesive. The models
were scanned with a 3-dimensional laser scanning machine, and the scanned
images were analyzed by using modified analytical software. Adhesive thickness
and enamel loss due to orthodontic procedures can successfully be measured in
vitro by using 3-dimensional laser scanning technology. 67
Fig . Scanned images with 4000 representative points (heart) for superposing
A, baseline with B, similar selected tooth area after bracket debonding. Area for
superposing is unchanged on tooth surface.
63
What types of analysis are available?
A number of analyses have been reported in the literature. These techniques are
often extensions from traditional methods of analysis using landmarks and points.
Future analysis will focus on the use of surface areas and volumes for evaluation
and quantification of diagnostic parameters and treatment changes. 7
Where are we with this technology?

Surface imaging and hard tissue imaging is revolutionizing the orthodontic
specialty. To date, there are dozens of schools in the United States that possess
both the surface imaging system and cone beam technology. In the next few years,
there will be several papers in the literature discussing diagnostic and clinical
outcomes and applications. 7
Are there limitations in the systems?

Yes, there are. Take the CBCT device, for example. It is excellent in imaging
hard tissue structures and most soft tissue components; however, it does not have
the ability to precisely map out the muscle structures and their attachments. These
intricate structures would have to be imaged using conventional magnetic
resonance imaging (MRI) technology, which incidentally does not predispose the
patient to radiation exposure.
In addition, the CBCT soft tissue images do not capture the true color texture of
the skin. Therefore, in order to obtain photograph-quality resolution, manipulation
of the images is still required. Successful attempts to map tissue texture maps onto
conventional CTs have been reported and may be similarly applied to this new
technology. When they become available, perhaps they can successfully replace
the photographs taken during records. Another criticism made is the long capture
time for a full view of a subject (scan time of 30-40 seconds), during which
involuntary muscle movements (nostrils and breathing) lead to inaccuracies in
64
soft tissue capture. These limitations mean that the 3D devices like stereo-
photogrammetry and laser scanning are still better soft tissue alternatives for
surface texture capture. 7
Reliability of a three dimensional method for measuring facial animation:

Facial animation forms the foundation for our instinctive emotional
communications.77,78
Individuals with functional impairment and/or facial disfigurement lose, to
varying degrees, this vital, innate form of communication. To date, there have
been several attempts to quantify facial function or animation in the form of two-
dimensional linear and angular measurements and by studying facial expres-
sions.78-83
More recently, Frey and co-workers51,84 conducted a three-dimensional analysis
of facial expressions by means of a method similar to the one proposed in this
study. The results of their study were promising; however, the reliability of this
method was not characterized clearly.
Reliable methods of quantifying functional impairment of the craniofacial region
are sorely lacking. Subjects were instructed to perform repeated sequences of five
maximal facial animations. Facial motions were captured by three 60-Hz video
cameras, and three-dimensional maximum motion amplitudes were calculated.
Moderate to excellent reliability of the amplitude of motion for the landmarks
over all animations. For each specific animation, certain landmarks demonstrated
excellent reliability of motion.85
Evaluation of the Validity of Tooth Size and Arch Width Measurements Using
Conventional and Three-dimensional Virtual Orthodontic Models
Measurements and different analyses of dental casts are essential for precise
diagnosis of an orthodontic case. At present, virtual computerized models, such as
OrthoCAD, are available for clinicians, supplemented by dedicated software for
performing needed measurements on them.
65
Zilberman et al., evaluate of the validity of tooth size and arch w idth
measurements using conventional and three-dimensional virtual orthodontic
models they showed that the methods being highly valid and reproducible for both
tooth size and arch width. For the tested clinically applicable methods,
measurement with digital calipers on plaster models showed the highest accuracy
and reproducibility, closely followed by OrthoCAD. Digital calipers seem to be a
more suitable instrument for scientific work. However, OrthoCAD’s accuracy is
clinically acceptable, and most likely, considering its present advantages and
future possibilities, the examined or an equivalent 3D virtual models’ procedure
would become the standard for orthodontic clinical use. 86
Measurement with digital calipers on plaster models produced the most
accurate and reproducible results. 86
The OrthoCAD measurement tool showed high accuracy and reproducibility
but was inferior to measurements done on plaster models with digital calipers. 86
Figure . Measurements of mesiodistal width of (a) incisor, (b) canine, (c)

premolar, and (d) molar using the OrthoCAD tool, as
shown from different views.
Figure 2. Measurements of (A) intercanine and (B)

intermolar distances using the OrthoCAD tool. The upper
(u) measurements are made between the tip of the cusps,
and the lower (l) between the gingival margins of the teeth. 86
66
Radiation exposure
Even though the cone beam technology is able to provide three-dimensional
volumetric images with up to four times less radiation than a conventional CT,87
the resulting effective radiation is dependent on the settings used (kVp and mA).
The use of lower mAs and/or collimation are some of the ways to reduce the
amount of radiation the patient receives, but at the same time can produce a lower
image quality than by using higher settings. Patient effective exposure dose from
a CBCT machine has been reported to be as low as 45 mSv to as high as 650 mSv.
As a reference, published exposure for an analogue full mouth series has been
reported as 150 mSv;88 for an analogue panoramic radiograph as 54 mSv 89 and a
round trip from Paris to Tokyo adds 139 mSv of effective dose to each
passenger.90,91 In 2001, an article associating the use of conventional CT in
children to radiation-induced fatal cancer92 raised some controversial concepts. As
a result, CTs were adjusted to have a decrease in effective dose from 6000 to 2600
mSv.93 Even at the highest settings and best image quality possible, none of the
CBCT machines come close to those values. 18
The British Orthodontic Society Guidelines suggests that: ‘Radiographs should
only be justified when the management of patient is dependent on the information
obtained’.94 The ADA Council on Scientific Affairs recommends the use of
techniques that would reduce the amount of radiation received during dental
radiography. Known as the ‘As Low As Reasonably Achievable’, or ALARA,
principle, this includes taking radiographs based on the patient’s needs (as
determined by an examination), using the fastest film compatible with the
diagnostic task, collimating the beam to a size as close to that of the film as
feasible and using leaded aprons and thyroid shields. 18
An accepted ratio between exposure and image quality needs to be reached in
order to use the ALARA principle. Depending on the objective and desired
outcome, alternative technologies should be explored since they may offer a less
67
invasive three-dimensional technology.95–99 The below figure demonstrates soft
tissue scans of a growing patient analysed every 6 months and is produced using
two Minolta VI 900 laser scanners and RapidFormTM Imaging Software.18
Figure Use of three-dimensional non-invasive soft tissue imaging devices to

study longitudinal growth changes in children
What are the costs involved?
These devices are expensive in the current market. A surface imaging device
costs approximately $50,000, whereas the cone beam technology costs $200,000.
The cost of a maintenance contract for each machine is often 10% of the retail
price. Another substantial cost to consider is the need for someone to operate the
machines as well as someone to interpret the results. 7
68
What is the best clinical setting for the different imaging devices?
At present, the best clinical setting is a pooled resource center. These centers
often take the form of a designated imaging laboratory or faculty institution. Hard
and soft tissue images can be imaged and transited to the doctor's office via
weblink or CD-ROM. 7
Are there medico-legal issues with these devices?

Yes and no. It is less likely that surface capture systems will pose a problem
unless the surface scans are used for advertisements or teaching, patient consent is
required in such circumstances. The main problem arises when CBCT radiation
technology is used. The issues of radiation protection and clinical diagnosis
become more evident at this point. For example, is the orthodontist responsible,
for the diagnosis of pathology outside of the realms of his clinical responsibility?
Some clinicians "get around" the problem by informing their patients in writing
that they are responsible for only the orthodontic diagnosis. These patients are
encouraged to seek the advice of other specialists.
At present there are no strict guidelines governing these issues, although in the
future there most certainly will be regulations in these areas to protect both the
clinician and the, patient. 7
What does the future hold?

The future for orthodontists is promising and bright. The long-awaited
incorporation of the third dimension to our soft tissue and radiographic records is
now a reality. There is still room for improvement, but these technologies appear
to be here to stay. 7
69
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Am J Orthod Dentofac Orthop. 2005; 584–91.
Dr. Ramadan yousof abou shahba (B.D.S., M.SC, Ph D)

Lecturer of Orthodontics, Faculty of Dental Medicine, Al-Azhar University,
(Boys-Cairo)
rabushahba@yahoo.com
El-Hassanein Hussein El-Hassanein (B.D.S., M.SC)
Assistant lecturer, Orthodontic Department, Faculty of Dental Medicine, Al-
Azhar University
(Boys-Cairo)
elhassanein@hotmail.com
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Al-Azhar University

Faculty of Dental Medicine

Three Dimensional imaging in orthodontics

The use of lateral cephalometric radiographs forms an important diagnostic tool

The Limitations of Radiographic Cephalometry

What does it mean to have a three-dimensional image and how is it obtained?

Right-handed xyz coordinates system

TABLE 5-1 Tabular Representation of Surface Imaging Devices

METHOD SOURCE INDUSTRY EXAMPLES

lasers 670-690 nm a. Fixed Units

Laser scanning (3D laser scanning)

Vision-based scanning techniques

3D Facial Morphometry (3DFM)

Computerized tomography, CT or (computerized axial tomography, CAT) and

Conventional computerized tomography (CT)

Cone-beam computerized tomography (CBCT)

Specification of the currently available cone beam CT machines approved for

Trade NewTom i-CATTM Cone CB 3D

Tube 110 kVP 120 kVP 60–120 kVP 60–789

Tube 15 mA 3–8 mA 10–15 mA 1–10 mA

Scan 36 seconds 10–40 seconds 10 seconds 17

Image Image Amorphous flat Image Image

Grayscale 12 bit 12 bit 12 bit 8 bit

Field of 99 mm (6- 250 (diameter) x 102.4 mm (6- 40

Reconstru 2 minutes 1.5 minute 6 minutes 5 minutes

Website www.qrver www.imagingscie www.hitachim www.jm

Complete 3d patient records

Classification of three dimensional orthodontic records

A) The Three Dimensional Face (3D imaging of the face)

Structured light techniques

3D Facial Morphometry (3DFM)

Laser-based scanning techniques

Radiation-based scanning techniques

B) The Three Dimensional Craniofacial Skeleton

C) The Three Dimensional Dentition

Digital 3D dental casts can be produced either directly or indirectly.

2). Indirect Method:

Holography was introduced in 1948 and involved microscopy by reconstructed

3D Models created out of CT images. A) Craniofacial

This yields a clear visual understanding of the critical relationships between

Fig. View of a digitally stored model.

3-D Cephalometric Imaging Versus Traditional 2-D Approach

Figure Schematic diagram showing the location of the anatomical landmarks.

Measuring the Human Face

In 1994, Jacobson and Gereb developed a 3-D cephalometric analysis.

3-D Cephalometric Analysis

Inferior facial plane. This is a

Posterior facial plane. This is a

Left and right lateral facial planes.

What are some clinical applications?

Fig . Overlay of 3D surface models: A and B, pretreatment and posttreatment

Fig. Skeletal changes in 3D superimpositions of pretreatment and 1-year

Surgical patients and those with syndromes and clefts

Impacted Teeth and Oral Abnormalities

Alveolar bone resorption and the center of resistance modification

Temporomandibular Joint (TMJ) Morphology and Assessment

Tongue size and Posture

Planning for placement of dental implants

Analysis of tooth movement in extraction cases

Fig . 3D laser scanner and the model on the rotating stage.

Fig . Aligning the models with the shell tracker ball.

Fig . Regional registration by selecting a

Fig . Superimposed pretreatment and

Fig . Digital dental cast.