Recent Advances in Diagnostic Aids and

Treatment planning

Moderator: Dr Sujala
Presented by: N. Shweta
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Contents:
• Orthodontic diagnostic records
• Conventional diagnostic records
• Recent Advances in Imaging technique
Digital Radiography
Digital Cephalometry
Digigraph
Dicom
Holograms
3D Imaging Techniques
Computed Tomography
CBCT
MRI
3D Cephalometrics
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• Recent Advances in Study models
Stereo photogrammetry
Structured Light Scanning
Laser Scanning
Ortho CAD
E Models
• Recent Advances in Photography
3D photography
• Recent Advances in Treatment Planning
Sure Smile Technology
Surgical Prediction Software
• Recent Advancements in Examination of Function
T Scan
Electromyography
Arthroscopy
Mandibular movement trackers 3
Orthodontic Diagnostic Records:

Alignment and
Health of Teeth and
occlusal
Oral Structures
relationships

Facial and Jaw

Proportions

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Conventional Orthodontic Diagnostic Records:

• Study models

• Radiographic Images
Cephalometric Radiographs
Panoramic Projections
Periapical Projections
Bitewing and Occlusal radiographs

• Intra oral and Extra oral Photographs

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Recent Advancements in Imaging Techniques

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Digital Radiography

■ Digital radiography is possible since Trophy introduced the first

Charge coupled device (CCD) in mid- 80’s

■ Patient radiation exposure can be reduced by 30% - 98%

Sensor

Electrical
X Ray charge
• CCDs digitizer
• Amorphous Selenium Image
• Amorphous Silicon
• Phosphor plates 7
X-ray imaging with CCD

• Scintillator- converts x-radiation to photons

(light)
• Fibre optic layer conducts photons to CCD stops
x-radiation
• CCD- converts photons to electrons (charge)
• Electronic circuit amplifies the signal and
converts the analog signal to digital
pixels

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DenOptix
A radiographic technique which eliminates silver halide film
Instead uses Storage Phosphor imaging plates
Advantage over CCD - no rigid sensors and wires, also less expensive

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■ Imaging cycle

1.Load intraoral or panoramic

imaging plate
5. Erase imaging plates
for reuse

2. Take X ray
Image on computer

3. Mount imaging plates in carousel 4. Place in scanner & Scan images 10

Advantages

- Alternative to conventional film

- Same machine and settings used for DenOptix and regular cephs & OPGs
- No dark room required
- Environment friendly- no heavy metal wastage
- Can be reused
- Transmission of images
- Saving staff time

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Digitization of Cephalometrics:

• Direct computer digitization

• Indirect computer digitization

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Direct computer measurement

• The cephalogram is placed on a digitizing tablet, and the anatomy and

anatomical points are entered into computer through the use of an
electronic pen or instrument
• Digitizing tablet: is made up of a fine electronic grid that includes
registration points as fine as .009mm apart
• Electronic pen: Also called as potentiometer & is of two types:

Pen type
Cross hair cursor
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Pen type: An electronic pen is activated to emit signals when the tip of the
pen is depressed against the cephalogram

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Cross hair cursor: This potentiometer comprises of two wires arranged in a
cross-hair pattern, which are imbedded into a glass window. The electronic
signal is emitted from the junction of the wires. The points to be digitized
are identified by the clinician, the crosshair directly placed on the point, and
the potentiometer is then activated with a button on the instrument. An
electronic signal is emitted, picked up by the grid, and registered in
computer memory.

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Advantages:
 Once data entry is complete, the computer can instantly reconstructs the
data in the form of conventional tracing or print out.
 Many analysis made instantly

Disadvantages:
Instrument tends to block the view of the rest of the film
Point identification very difficult
Glare from the glass

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Indirect digitization

A video camera or scanner captures an image of the ceph & stores it in

computer. Once the image is captured and stored in the computer, image is
then displayed on the monitor and indirectly digitized via a mouse or an on-
screen electronic pen

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 Comparing hand tracing with computer digitization

• Richardson(1981) investigated the precision of directly digitized

cephalogram and hand traced cephalogram .He concluded that there
is not much of difference in both methods in terms of accuracy.

• In a study by Houston(1982),he concluded that the errors associated

between the two groups was significantly insignificant.

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 DIGIGRAPH

 Introduced by Dolphin imaging systems

 Non-radiographic system
 ‘Digi graph workstation’
 Video images also possible
 Reduces time required for records.

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• The DigiGraph Work Station is about 5 feet long, 3 feet wide and 7
feet high.

• The main cabinet contains the electronic circuit, and the patient sits
next to the cabinet in an adjustable chair.

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• The video monitor is attached that can be rotated as the operator moves. Images are as
sharp as those on a standard color television. The images, text, and numerical data can
be displayed, stored, and modified using either a light pen or a standard computer
keyboard.

• The digitizing handpiece is used to record cephalometric data while the patient is in the
head holder. The removable, sterilizable tip of the handpiece is placed directly on the
patient to record a series of facial and intraoral landmarks. As each landmark is located,
the handpiece button is depressed and the location is recorded in three-dimensional
coordinates (x,y,z).

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Digitizing is done in this order:

1) facial landmarks
2) mouth-closed intraoral landmarks
3) intraoral landmarks requiring a disposable bite opener to be inserted.
4) extrapolated landmarks:
Such frequently used points as sella, incisor root apices, and anterior
nasal spine cannot be measured directly from the patient using the
digitizer. Locations of these points are calculated by the program based
on the locations of other related landmarks, using specific mathematical
algorithms.

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Various Cephalometric Analyses that can be done are:
• Ricketts lateral
• Ricketts frontal
• Holdaway
• Alabama
• Jarabak
• Steiner
• Downs
• Burstone
• McNamara
• Tweed
• Grummons frontal
• Standard lateral
• Standard frontal 24
Visual Treatment Objective

To move part of the picture, simply touch the

light pen to two points on the screen, at opposite
extremes of the area to be moved. The computer
draws a box with the two points at opposite
corners. Then, by touching the light pen to
another spot on the screen, the boxed image is
moved to that spot. Boxes can be moved
vertically, horizontally, or diagonally, or they
can be rotated about any point.

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Standardization of data

• In 1983, the American College of Radiology joined with the National Electrical
Manufacturers Association to form a committee dedicated to creating a standard method
for transferring images and associated information between devices manufactured by
different vendors.

• In 1985, they released the first version of what called standard version 1.0, with version
2.0 released in 1988. This version prompted medical device manufacturers to adopt the
standard, thus further streamlining medical imaging for everyone involved—including
software developers, practitioners, and patients.

• In 1993, version 3.0 was released with a name change to Digital Imaging and
Communication in Medicine (DICOM), in hopes of improving international acceptance.

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 Holography
• Holography is a photographic
technique for recording and
reconstructing images in such a way
that the three-dimensional aspect of
an object can be retained.
• The recorded image is called a
hologram.
• Experimental apparatus consists of a
flat optical table with air suspension.
The illumination for recording and
reconstruction of holograms was
provided by a 15 mW He-Ne laser.
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Orthodontic applications

■ Storage of study models

■ Measurement of incisor intrusion
■ Study of the effects high pull head gear traction in human
children skulls.
■ Effect of class-II elastics on bone displacements.
■ Effect of cervical pull head gear on maxilla
■ Determine centers of rotation produced by orthodontic forces.
■ Lower incisor space analysis
■ To assess facial and dental arch symmetries.
Drawbacks of 2D Imaging:

• Two dimensional representation of a three dimensional object

• Cephalometric analyses are based on an assumption of perfect

superimposition of right and left sides about the mid sagittal plane

• Radiographic projections errors in magnification, patient positioning

and distortion is seen

• Manual data collection and processing has been shown to have low
precision

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 3D IMAGING
Selected digital imaging devices can produce digital volumes or 3D
images. The volume element (voxel) is the smallest element of a
3-dimensional image. A voxel volume can be thought of as a 3D array or
stack of bitmapped images, with each voxel having height, width, and
thickness.

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Computed Tomography

 Invented by Sir Godfrey Hounsfield in 1972 who was awarded a Nobel prize in
1979

 CT is an image display of the anatomy of a thin slice of the body developed from
multiple x- ray absorption measurements made around the body’s periphery

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ADVANTAGES OF CT:

 Completely eliminates the super imposition of images of structures.

 Differences may be distinguished between tissues.
 Multi planning imaging is possible.
 Confines the radiation to the plane of interest.
 Minimizes blurring.
 Permits visualization of small variations in tissue density.
 CT produces superb contrast resolution of soft tissues.
 CT image without using invasive contrast material.

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 Three dimensional computed tomography
The first application of 3D CT was in 1980 for suspected inter- vertebral
disc herniation and spinal stenosis.
Uses:
•Treatment planning with 3d cephalometry.
•Treatment prediction.-orthodontic or orthognathic
•3D Reconstruction
TMJ
Tongue and airway dimensions.
3-D CT study models.
DISADVANTAGES OF CT:

 Time consuming.
 Expensive for routine clinical use.
 Patient is exposed to high amounts of radiation.
 The equipment is very expensive and therefore not always
accessible.

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Advancements in Computed Tomography

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SPIRAL CT
■ Spiral CT (SCT or volume acquisition CT).
■ By simultaneous patient translation through the x-ray source with
continuous rotation of the source-detector assembly, SCT acquires raw
projection data with a spiral sampling locus in a relatively short period.
Without any additional scanning time, these data can be viewed as
conventional trans axial images, as multiplanar reconstructions, or as
three-dimensional (3D) reconstructions. Such images provide an
opportunity to obtain accurate images at any arbitrary location within the
volume data set.

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Cone-Beam Computed Tomography (CBCT)

■ Cone-shaped X-ray beam is directed through the patient and the

remnant beam is captured on a flat two-dimensional (2D) detector

■ The X-ray source and detector are able to revolve about a patient’s
head, and a sequence of two-dimensional (2D) images is
generated.

■ These 2D images are then converted into a 3D image using

computer software.

■ The rapid movement of the X-ray tube and digital detector through
180°/ 360°, produce 2D and 3D radiographic images of an
anatomical structure.
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New tom 9000 first
CBCT machine

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Advantages of CBCT over conventional CT

1. It is less expensive and involves a smaller system.

2. The X-ray beam is limited.
3. Accurate images are obtained.
4. The scan time is rapid.
5. A lower radiation dose is used.
6. The display modes are exclusive to dentofacial imaging.
7. There are fewer imaging artifacts.

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Disadvantages

■ Presence of metal brackets, restorations can produce poor quality

images

■ The Muscles and soft tissue images cannot be determined.

■ Unwanted patient movement may cause image distortion.

■ Price of these devices is more expensive than conventional X-ray

equipment, and these devices require more space

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Applications in Orthodontics

Diagnosis:-
■ Assessment of skeletal structures and dental structures
■ Skeletal jaw relation
■ Symmetry/asymmetry
■ 3D evaluation of impacted tooth position and anatomy
■ Growth assessment
■ Pharyngeal airway analysis
■ Assessment of the TMJ complex in three dimensions
■ Cleft palate assessment

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 CBCT image of impacted upper left canine

CBCT image for airway analysis. CBCT image of a patient with unilateral cleft palate.

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Treatment planning:-

■ Orthognathic surgery treatment planning

■ Planning for placement of temporary anchorage devices (TADs)
■ Accurate estimation to space requirement for unerupted/ impacted
teeth
■ Used in association with CAD/ CAM technology for construction of
custom appliances. (Lingual orthodontic appliance)

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Surgical simulation to plan
displacement of colored segments.

Planning of TAD placement.

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Treatment progress:-
■ Assessment of dentofacial orthopedics
■ Outcomes of alveolar bone grafts in cleft palate cases
■ Orthognathic Surgery superimposition

Risk assessment:-
■ Investigation of orthodontic-associated paraesthesia
■ Assessment of orthodontics induced root resorption
■ Post treatment TMD

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Orthognathic superimposition with CBCT imaging
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Comparison of two cone beam computed tomographic systems versus panoramic
imaging for localization of impacted maxillary canines and detection of root resorption:
(European Journal of Orthodontics 33 (2011) 93–102)

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Digital orthodontic radiographic set versus cone-beam computed tomography:
an evaluation of the effective dose (Dental Press J Orthod. 2016 July-Aug;21(4):66-72)

• The aim of this study was to compare the equivalent and effective doses of different digital radiographic
methods (panoramic, lateral cephalometric and periapical) with cone-beam computed tomography
(CBCT).
• Precalibrated thermoluminescent dosimeters were placed at 24 locations in an anthropomorphic
phantom (Alderson Rando Phantom, Alderson Research Laboratories, New York, NY, USA),
representing a medium sized adult.
• The equivalent doses and effective doses were calculated considering the recommendations of the
International Commission of Radiological Protection (ICRP) issued in 1990 and 2007
• Although the effective dose of the radiographic set corresponded to 17.5% (ICRP 1990) and 47.2%
(ICRP 2007) of the CBCT dose, the equivalent doses of skin, bone surface and muscle obtained by the
radiographic set were higher when compared to CBCT. However, in some areas, the radiation produced
by the orthodontic set was higher due to the complete periapical examination.
• Considering the optimization principle of radiation protection, i-CAT tomography should be used only
in specific and justified circumstances. Additionally, following the ALARA principle, single periapical
radiographies covering restricted areas are more suitable than the complete periapical examination

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Accuracy of reconstructed images from cone-beam computed
tomography scans- Am J Orthod Dentofacial Orthop 2009;136:156.e1-156.e6
Aim: To determine whether 2-dimensional (2D) images produced from cone-beam computed tomography
(CBCT) images taken with an iCAT scanner (Imaging Sciences International, Hatfield, Pa) can substitute for
traditional cephalograms.

Methods: Lateral and frontal cephalograms were taken of a radiographic phantom with known dimensions.
Landmarks on the 2D images were traced and measured manually by 2 examiners and then digitally in
Dolphin 10 (Dolphin Imaging Sciences, Chatsworth, Calif) by the same examiners. A CBCT scan was taken
of the phantom, and orthogonal and perspective projections were created from the scans. Frontal and lateral
cephalograms were created by using the 3-dimensional function in Dolphin 10, digitized into Dolphin, and
traced by the same 2 examiners.

Results: Measurements on the orthogonal projections were not significantly different from the actual
dimensions of the phantom, and measurements on the perspective projections were highly correlated with
those taken on standard 2D films.

Conclusions: By constructing a perspective lateral cephalogram from a CBCT scan, one can
replicate the inherent magnification of a conventional 2D lateral cephalogram with high accuracy
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Micro-computed tomography (MCT)

■ MCT is similar to CT except that the reconstructed cross-sections are bounded

to a much minor area

■ 0.012 mm thin cross-sections can be taken with conventional CT, but MCT can
be obtained with the nano-sized sections.

■ MCT devices have 10,000 times more resolution than medical CT scanners
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Applications:
■ Used for the analysis of mineralized tissues
■ To evaluate osteoblastic/osteoclastic alveolar remodeling
■ Bone dehiscence and root resorption
■ To assess osseo-integrated implants used for orthodontic
anchorage

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Tuned-aperture computer tomography (TACT)
■ Is developed by Richard Webber (Wake Forest University, School
of Medicine, Winston-Salem, North Caroline, USA)
■ Low-dose 3-dimensional imaging system.
■ The device consist of multi-tube X-ray and X-ray charge-coupled
device screen.

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Applications

■ Evaluation of dento-alveolar bone volume

■ To detect root resorption

■ Evaluation of the TMJ disorders

■ To detect impacted teeth

■ To evaluate pre-implant images

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Magnetic Resonance Imaging- MRI

•Equipment Gantry – houses the patient.

•Patient is surrounded by magnetic coils

•Magnetic fields are caused by rotating electric

charges.

•Essentially it is the- imaging of the water in

the tissue.

•Images are generated from protons of the

hydrogen nuclei of water
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 Indications
■ MRI imaging of TMJ
■ Cleft lip and palate
■ Tonsillitis and adenoiditis,
optimum assessment of upper
airway
■ Cysts, infections and tumors
Contraindications
■ Patients with cardiac pacemakers.
■ Patients with cerebral metallic
aneurysm clips.- Slight movement
of the clip could produce bleeding
■ Stainless steel and other metals
produce artifacts , obliterate image
details of the facial area.
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 Importance of MRI imaging of the TMJ

• Determine
the structural relationship between the Condyle, Articular disc
and Glenoid fossa

• Detect inflammation, hematoma and effusion for the soft tissue

components
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3D Cephalometrics

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Comparison of two three-dimensional cephalometric analysis computer
software (Journal of Orthodontic Science Vol. 3 | Issue 4 | Oct-Dec 2014)

InVivodental 5.0 3D Ceph

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Conclusion:

• InvivoDental5.0 is a more user friendly and convenient program to use for

three-dimensional cephalometric analysis of CBCT images.

• Clinicians must also take into account the benefit of using CBCT generated
cephalometric images and volumetric DICOM files as opposed to conventional
2D diagnostic images as conventional cephalometric radiographs cannot be used
with InvivoDental5.0 software to obtain three dimensional measurements.

• However, this statement should be interpreted with high care that although
CBCT generated images are more accurate than regular 2D cephalometric
radiographs, increased radiation with CBCT still is a question about routine use
of CBCT in daily clinical practice.

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Recent Advances in Study Model Analysis

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DIGITAL MODELS

■ Stereo photogrammetry

■ Laser scanning

■ Structured light scanning

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Stereophotogrammetry

■ Most common class of 3D surface imaging system

■ These systems are capable of accurately reproducing the surface
geometry of the face, and map realistic color and texture data onto the
geometric shape resulting in a lifelike rendering
■ The basic principle is based on binocular vision
■ When 2 photographs of the same object are taken from slightly
separated points, they can be viewed in a manner that will give a 3D
model surface.
■ It permits a mathematical & geographic analysis of solid object like
casts
■ It can supply more analytical information than graphic tracing methods

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Structured light Scanning

■ To perform surface height measurements of an object using Coherence

Scanning Interferometer (CSI) with spectrally-broadband, "white light"
illumination.

■ Different configurations of scanning interferometer may be used to

measure macroscopic objects with surface profiles measuring in the
centimeter range, to microscopic objects with surface profiles measuring
in the micrometer range

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They project an organized light pattern
of grids, dots, stripes, and other designs
onto the surface of the object

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Advantages

■ Structured light systems can obtain rapidly captured photorealistic

images in a noninvasive manner.
■ The structured light system uses white light, which can be safely
viewed with the naked eye.
■ The high speed and safe light source mean that this approach can be
used in long-term studies and those involving children and large
population samples

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Optical 3D scans for orthodontic diagnostics performed on full-arch impressions.
Completeness of surface structure representation (J Orofac Orthop 2015; 76:1-15)

• Three pairs of full-arch resin models were used as reference, characterized either by
normal occlusion, by anterior diastematic protrusion (and edentulous spaces in the lower
posterior segments), or by anterior crowding.
• An alginate impression of each arch was taken and digitized with a structured-light
scanner, followed by three rescans with the impression cut back to 10, 5, and 1 mm of
gingival height. Each impression scan was analyzed for quantitative completeness relative
to its homologous direct scan of the original resin model. In addition, the topography of
voids in the resultant digital model was assessed by visual inspection.

• In strictly quantitative terms, the impression scans did capture relatively large
percentages of the total surface. However, the topographic examinations revealed that
regions essential for orthodontic model analysis were missing. The malocclusion models
were particularly affected. Thus, impression scans performed with structured-light
scanners cannot replace scans of positive casts for diagnostic use in orthodontics
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Laser Scanning:

■ Laser scanners are capable of producing detailed models

■ Laser scanner provides only surface map and not color information for
the texture map and hence a color camera is registered with the scanner

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Digitalizing Study Models:

■ The two major computerized model systems creating digital models are
OrthoCADTM (Cadenrt, Inc, Fairview, NJ) and emodelsTM (GeoDigm,
Corp, Chanbassen, MN)

OrthoCADTM
■ First company to introduce a digital model service in 1999.
■ The startup software for OrthoCADTM is free of charge and is about 8
megabytes in size.
■ The cost is approximately same as for a laboratory charge for a set of
trimmed study casts.
■ OrthoCAD’s – 3-D browser software allows the clinician five
simultaneous views of the models. 73
Ortho CAD:

• It is a digital study model capture, assessment and storage system.

• It provides a 3D record of the original malocclusion, any stages during treatment and
the outcome of the treatment. 74
Bracket Positioning

Wand with miniature video camera, LED and tip

Viewing the teeth on monitor screen with the wand

and temporarily setting the bracket on the tooth

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ORTHOCAD BRACKET PLACEMENT

Initial bracket placement

Adjusting to the correct

Final correct bracket placement position

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■ It can also make measurement in any plane
of space. E.g., Bolton analysis, Tanaka
Johnson analysis
■ It also features of cross-sectional tool (Jaws
Alignment Tool) that can slice the digital
models in any vertical or horizontal plane
■ It also has a occlusogram feature.
■ OrthoCAD’s Virtual Set-Up enables the
clinician to simulate and visualize any
desired treatment option including virtual
extractions, interproximal reduction,
expansion leveling, and to apply various
fixed appliances

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emodels TM

■ Founded in 1996 by GeoDigm as interactive reflective imaging system

■ Software size 12MB compare to 8MB of OrthoCAD
■ More expensive
■ Has the facility of simultaneous viewing, tooth measurement in any
plane of space, cross sectional tool
■ The most useful feature is eplanTM – virtual diagnostic setup

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Variations in orthodontic treatment planning decisions of Class II patients
between virtual 3-dimensional models and traditional plaster study
models (Am J Orthod Dentofacial Orthop 2006;130:485-91)
• Ten sets of records of Class II malocclusion subjects (dental study models, lateral
cephalograms/tracings,panoramic radiographs, intraoral and extraoral photographs)
were used for treatment planning by 20 orthodontists on 2 separate occasions.
• Digital models were used to evaluate the patients at 1 session and plaster models
were used at the other session. Treatment recommendations were scored and
compared for agreement. Eleven orthodontists served as the control group, looking at
the records on 2 occasions with plaster models for agreement.
• Overall proportions of agreement ranged between 0.777 and 0.870 for digital/plaster
and 0.818 and 0.873 for plaster/plaster.
• There was no statistical difference in intrarater treatment-planning agreement for
Class II malocclusions based on the use of digital models in place of traditional
plaster models.
• Digital orthodontic study models (e-models) are a valid alternative to traditional
plaster study models in treatment planning for Class II malocclusion patients.
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Digital casts in orthodontics: A comparison of 4 software systems
(Am J Orthod Dentofacial Orthop 2015;147:509-16)

• The aim of the study was to compare 4 orthodontic digital software systems regarding service, features,
and usability.

• Information regarding service offered by the companies was obtained from questionnaires and Web sites

• Replicas of pretreatment casts were sent to Cadent (OrthoCAD; Cadent, Carlstadt, NJ), OthoLab
(O3DM; OrthoLab, Poznan, Poland), OrthoProof (DigiModel; OrthoProof, Nieuwegein, The
Netherlands), and 3Shape (OrthoAnalyzer; 3Shape, Copenhagen, Denmark).

• The usability of the programs was assessed by experts in interaction design and usability using the
“enhanced cognitive walkthrough” method: 4 tasks were defined and performed by a group of domain
experts while they were observed by usability experts

• The services provided by the companies were similar. Regarding the features, all 4 systems were able
to perform basic measurements. However, OrthoCAD and 03DM were considered to be easier to learn for
first-time users.
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A Comparison of the Accuracy of Linear Measurements Obtained from Cone Beam
Computerized Tomography Images and Digital Models- Semin Orthod. 2011 March 1; 17(1): 49–56

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Recent Advances in Photography

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Reproducibility and reliability of three-dimensional soft tissue landmark identification
using three-dimensional stereophotogrammetry( Angle Orthod March 2016)

• To evaluate the intraexaminer repeatability and interexaminer reproducibility of soft

tissue landmarks on three dimensional (3-D) stereophogrammetric images.
• Thirty-four stereophotogrammetric images were taken and 19 soft tissue points were
identified. The images were obtained using the 3-DMD Face (3-DMD TM Ltd, Atlanta,
Ga) system. Two examiners marked 34 images manually with a mouse-driven cursor 4
weekapart. Intraexaminer marking differences were calculated and classified as ,0.5 mm,
0.5–1 mm, and 1 mm.
• Only one landmark (labiale superior) had an intraexaminer marking difference less than
0.5 mm. Existing landmarks had an intraexaminer difference less than 1 mm, but higher
than 0.5 mm. The intraclass correlation coefficients (ICCs) indicated good intraexaminer
repeatability for both observers.
• All soft tissue landmarks were shown to have high reproducibility and reliability, both in
inter- and intraexaminer comparison.
• Soft tissue landmarks used in this study were shown to differ less than 1 mm between
repeated markings.
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Structured Light Imaging

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 3D Facial Imaging

■ Developed by D’ Arcy Thompson

■ Proposed by deCoster – 1930.
■ Again by Moorrees and Kean – 1950.
■ Modified by Ferrario et al. – 1998.
■ Allows rapid and independent quantifications of soft tissue facial size and shape in
the three-dimensional space.
■ Uses the collection of x, y and z coordinates of 22 soft tissue landmarks.
■ Detects the three-dimensional coordinates of retroreflective, wireless markers
positioned on selected facial landmarks with 2 charge-coupled device cameras.
■ A mesh of equidistant horizontal, vertical and antero-posterior lines is consequently
constructed and standardized
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THREE DIMENSIONAL IMAGE CAPTURING SYSTEM FOR
FACIAL PROFILES (C3D software)

The analog picture of a stereopair of video cameras are converted into a

digital mode with a standard frame grabber (A device for converting a
television picture to a digital array of numbers). The software does the
entire capture in 50 milliseconds

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3D imaging of the face enables the orthodontist to evaluate the face from
any direction. Here, a skeletal Class III case is displayed in different views

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Quantitative analysis of 3-dimensional facial soft tissue photographic images:
technical methods and clinical application- Nanda et al. Progress in Orthodontics (2015) 16:21

Background: The recent advent of 3D photography has created the potential for comprehensive facial
evaluation. However, lack of practical true 3D analysis of the information collected from 3D images has
been the factor limiting widespread utilization in orthodontics. Current evaluation of 3D facial soft
tissue images relies on subjective visual evaluation and 2D distances to assess facial disharmony. The
objectives of this project strive to map the surface and define boundaries of 3D facial soft tissue, modify
mathematical functions to average multiple 3D facial images, and mathematically average 3D facial
images allowing generation of color-coded surface deviation relative to a true average.

Conclusions: The results of this investigation suggest that it is possible to average multiple facial
images of highly variable topology. The immediate application of this research will be rapid and
detailed diagnostic imaging analysis for orthodontic and surgical treatment planning. There is great
potential for application to anthropometrics and genomics. This investigation resulted in establishment
of a protocol for mapping the surface of the human face in three dimensions.

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Recent Advances in Treatment Planning

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SURE SMILE SYSTEM
• The technique utilizes 3-D imaging, treatment planning software and a
robot to create the wires

• Suresmile incorporates intraoral scanning ,cone beam CT, special alloy

arch wires and precision robotic wire bending

• Designed to reduced errors in treatment resulting from appliance

management

• The technique is reported to decrease the time required to complete

orthodontic treatment by 34% and increase the precision of the results

(Saxe; et al. (2010). "Efficiency and Effectiveness of SureSmile". ORTHODONTICS The Art and
Practice of Dentofacial Enhancement, formerly World Journal of Orthodontics )
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SURE SMILE TECHNOLOGY

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Computer-assisted orthodontic treatment: The SureSmile process, AJODO July 2001
James Mah, DDS, MSc, DMSc,a and Rohit Sachdeva, BDS, MScb 97
Advantages

• The treatment time is faster

• The patient only has 1-2 wire changes compared to many wire
changes and/or adjustments with conventional braces.

• SureSmile all the bends to move teeth are made in a nickel titanium
wire and when it is placed into the patient’s mouth—their body
temperature activates those permanent bends to move teeth directly
into place.

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COMPUTERIZED SURGICAL PREDICTION IMAGING
A useful indicator of potential treatment outcomes with different techniques & the
orthodontist’s ability to achieve them
VIDEO IMAGING & PREDICTION:-

The software superimposes the patients lateral photograph onto the lateral cephalogram
to a proportionate scale. When the computerized predictions are made, the patient can
now have an idea of his / her probable facial appearance after the planned treatment.

Pre surgical Post surgical 99

PREDICTION IMAGING PROGRAMS

■ Prescription Planner/Portrait software system (PP)

■ Orthognathic Treatment Planner (OTP)
■ Dentofacial planner (DFP)
■ Quick Ceph (QC)
■ Dolphin Imaging (DI)
■ Vistadent (GAC)
■ Orthognathic Prediction Analysis (OPAL)
■ Nemoceph
■ Dr.Ceph
■ Maxilim software
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ADVANTAGES
1. Stored in computer memory
and recalled easily
2. Several alternative
predictions possible much
more rapidly
3. Enhancement of the doctor-
patient communication
4. Promotes greater
understanding and
satisfaction with the outcome
DISADVANTAGES
1. Software design dependent
and technique sensitive
2. Expensive
3. Poor soft tissue definition in
particular areas
4. Prediction is only a goal and
not a guarantee
101
A comparison of current prediction imaging programs
(Am J Orthod Dentofacial Orthop 2004;125:527-36)

• To investigate perceived differences in the ability of current software to simulate the actual outcome of
orthognathic surgery, 10 difficult test cases were chosen with vertical discrepancies and “retreated” them
using the actual surgical changes.

• Five programs—Dentofacial Planner Plus, Dolphin Imaging, Orthoplan, Quick Ceph Image, and
Vistadent—were evaluated, by using both the default result and a refined result created with each
program’s enhancement tools.

• Three panels (orthodontists, oral-maxillofacial surgeons, and laypersons) judged the default images and the
retouched simulations by ranking the simulations in side-by-side comparisons and by rating each
simulation relative to the actual outcome on a 6-point scale.

• For the default and retouched images, Dentofacial Planner Plus was judged the best default simulation
79% and 59% of the time, respectively, and its default images received the best (lowest) mean score (2.46)
on the 6-point scale. It also scored best (2.26) when the retouched images were compared, but the scores
for Dolphin Imaging (2.83) and Quick Ceph (3.03) improved.

102
Comparison of an Imaging Software and Manual Prediction of Soft Tissue Changes
after Orthognathic Surgery- Journal of Dentistry, (2012; Vol.9, No.3)

Objective: Accurate prediction of the surgical outcome is important in treating dentofacial deformities.
Visualized treatment objectives usually involve manual surgical simulation based on tracing of
cephalometric radiographs. Recent technical advancements have led to the use of computer assisted
imaging systems in treatment planning for orthognathic surgical cases. The purpose of this study was
to examine and compare the ability and reliability of digitization using Dolphin Imaging Software with
traditional manual techniques and to compare orthognathic prediction with actual outcomes.
Materials and Methods: Forty patients consisting of 35 women and 5 men (32 class III and 8 class II)
with no previous surgery were evaluated by manual tracing and indirect digitization using Dolphin
Imaging Software. Reliability of each method was assessed then the two techniques were compared
using paired t test.
Result: The nasal tip presented the least predicted error and higher reliability. The least accurate
regions in vertical plane were subnasal and upper lip, and subnasal and pogonion in horizontal plane.
There were no statistically significant differences between the predictions of groups with and without
genioplasty.
Conclusion: Computer-generated image prediction was suitable for patient education and
communication. However, efforts are still needed to improve accuracy and reliability of the prediction
program and to include changes in soft tissue tension and muscle strain
103
Recent Advances in Examination of Functions

104
T- Scan: Pressure mapping, Force measurement and Tactile sensors

105
Actions:

• Digital Impression Overlay feature shows T-Scan occlusal force data on

intraoral scans
• Implant loading alerts
• Upper and lower arch displays in 2D and 3D
• Force vs Time Graph – graph that shows force applied over time during
the length of bite
• Center of Force Target and Trajectory
• Force percentages by side, quadrant, and tooth

106
ELECTROMYOGRAPHY:
 Electromyography is a medical technique for evaluating and recording
physiologic properties of muscle at rest and while contracting.

 EMG is performed using a instrument called an electromyograph, to

produce a record called an electromyogram.

 An electromyograph detects the electrical potential generated by muscle

cells when these cells contract and also when cells are at rest.
USES:
 Helps to distinguish primary muscle conditions from muscle weakness
caused by neurologic disorders.
 It is used to find causes of muscle weakness, hyperactivity, paralysis
and involuntary twitching
 Abnormal muscle activity in Class II cases
 Children with cerebral palsy.
 EMG can be carried out after orthodontic therapy to see if muscle
balance is achieved.
■ To study muscle activity during treatment with functional appliance
Uses of electromyography in dentistry: An overview with meta-analysis
(Eurjdent October 2016)

Objective: The purpose of this study was to review the uses of electromyography (EMG) in
dentistry in the last few years in related research. EMG is an advanced technique to record and
evaluate muscle activity. In the previous days, EMG was only used for medical sciences, but now
EMG playing a tremendous role in medical as well as dental sector.

Materials and Methods: Several electronic databases such as Google Scholar, PubMed,
Science Direct, and Web of Science were systematically searched for studies published until July
2015.

Results: EMG can be used in both diagnosis and treatment purpose to record neuromuscular
activity. In dentistry, we can utilize EMG to evaluate muscular activity in function such as chewing
and biting or parafunctional activities such as clenching and bruxism. In case of TMJ and
myofascial pain disorders, EMG widely is used in the last few years.

Conclusions: EMG is one of biometric tests that occur in the modern evidence-based dentistry
practice.

109
TMJ Arthrography

• Radiographic invasive technique

• Uses a radio opaque substance (Tc99 / Ba )
• Injected into the joint space to enhance the contrast between disc
and the space
• Procedure:
 The joint is anesthetized
 0.5-1 ml of contrast media injected into the lower compartment and
1-1.5ml in the upper compartment
 Joint compartments are imaged

110
This procedure is not used now a days because of:
Patient discomfort
 allergic reactions
 chances of disc perforation
 time consuming
 relatively high radiation exposure

It is replaced by CT for bony components and MRI for the tissue components
111
Tracking Mandibular Movements:

Two Basic Approaches: Opticoelectric Methods

Ultrasonic Based Methods

112
The Future: 3D printers or Rapid Prototyping

113
 Orthodontic applications
1. Custom made brackets for individual patient anatomy of crowns.[lingual
brackets]

2. Various mock surgery procedures can be practiced on the 3D

Biomodels, allowing optimal input into the management decision, pre-
operative planning and choice of surgical technique.

114
• Fabrication of removable appliances

• Surgical template for implant

placement

• Impression trays for indirect bonding

• Distractor in distraction osteogenesis

• Surgical splints after orthognathic

surgery

115
Wire Bending Robots

116
Lingual Wire Bending Robots

LAMDA SYSTEM
117
References:
• Orthodontics- Current Principles and Practice- Graber, Vanarsadall and
Vig- 4th Edition
• Contemporary Orthodontics- Proffit, Fields and Sarver- 5th Edition
• History of imaging in orthodontics from Broadbent to cone-beam
computed tomography-Am J Orthod Dentofacial Orthop 2015;148:914-
21)
• Three-dimensional craniofacial imaging-Am J Orthod Dentofacial Orthop
2004;126:308-9
• Evolution of imaging and management systems in orthodontics- Am J
Orthod Dentofacial Orthop 2016;149:798-805
• Working with DICOM craniofacial images- Am J Orthod Dentofacial
Orthop. 2009 September ; 136(3): 460–470
• Computer-assisted orthodontic treatment: The SureSmile process- Am J
Orthod Dentofacial Orthop 2001;120:85-7 118
• Comparison of two cone beam computed tomographic systems versus
panoramic imaging for localization of impacted maxillary canines and
detection of root resorption: (European Journal of Orthodontics 33 (2011)
93–102)
• Digital orthodontic radiographic set versus cone-beam computed
tomography: an evaluation of the effective dose (Dental Press J Orthod.
2016 July-Aug;21(4):66-72)
• Accuracy of reconstructed images from cone-beam computed tomography
scans- Am J Orthod Dentofacial Orthop 2009;136:156.e1-156.e6
• Comparison of two three-dimensional cephalometric analysis computer
software (Journal of Orthodontic Science Vol. 3 | Issue 4 | Oct-Dec 2014)
• Optical 3D scans for orthodontic diagnostics performed on full-arch
impressions. Completeness of surface structure representation (J Orofac
Orthop 2015; 76:1-15)
119
• Variations in orthodontic treatment planning decisions of Class II patients
between virtual 3-dimensional models and traditional plaster study models
(Am J Orthod Dentofacial Orthop 2006;130:485-91)
• Digital casts in orthodontics: A comparison of 4 software systems -Am J
Orthod Dentofacial Orthop 2015;147:509-16)
• A Comparison of the Accuracy of Linear Measurements Obtained from
Cone Beam Computerized Tomography Images and Digital Models-
Semin Orthod. 2011 March 1; 17(1): 49–56
• Reproducibility and reliability of three-dimensional soft tissue landmark
identification using three-dimensional stereophotogrammetry( Angle
Orthod March 2016)
• Quantitative analysis of 3-dimensional facial soft tissue photographic
images: technical methods and clinical application- Nanda et al. Progress
in Orthodontics (2015) 16:21
120
• A comparison of current prediction imaging programs- (Am J Orthod
Dentofacial Orthop 2004;125:527-36)
• Comparison of an Imaging Software and Manual Prediction of Soft Tissue
Changes after Orthognathic Surgery- Journal of Dentistry, (2012; Vol.9,
No.3)
• Uses of electromyography in dentistry: An overview with meta-analysis
(Eurjdent October 2016)
• A Review on Robot in Prosthodontics and Orthodontics- Advances in
Mechanical Engineering · February 2014
• Fundamentals of Stereolithography, an Useful Tool for Diagnosis in
Dentistry- Int. J. Dent. Sc.No.17-1 2015.

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It has been said that in life two things are inevitable: death and taxes. May I
add a third (though not so vital): the application of the computer to orthodontic
research and diagnosis.
-Wilton Marion Krogman, forensic
anthropologist 122