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ORIGINAL ARTICLE

Orthodontic soft-tissue parameters: A comparison of cone-beam computed tomography and the 3dMD imaging system
Tasha E. Metzger,a Katherine S. Kula,b George J. Eckert,c and Ahmed A. Ghoneimad Indianapolis, Ind, and Cairo, Egypt

Introduction: Orthodontists rely heavily on soft-tissue analysis to determine facial esthetics and treatment stability. The aim of this retrospective study was to determine the equivalence of soft-tissue measurements between the 3dMD imaging system (3dMD, Atlanta, Ga) and the segmented skin surface images derived from cone-beam computed tomography. Methods: Seventy preexisting 3dMD facial photographs and conebeam computed tomography scans taken within minutes of each other for the same subjects were registered in 3 dimensions and superimposed using Vultus (3dMD) software. After reliability studies, 28 soft-tissue measurements were recorded with both imaging modalities and compared to analyze their equivalence. Intraclass correlation coefficients and Bland-Altman plots were used to assess interexaminer and intraexaminer repeatability and agreement. Summary statistics were calculated for all measurements. To demonstrate equivalence of the 2 methods, the difference needed a 95% confidence interval contained entirely within the equivalence limits defined by the repeatability results. Results: Statistically significant differences were reported for the vermilion height, mouth width, total facial width, mouth symmetry, soft-tissue lip thickness, and eye symmetry. Conclusions: There are areas of nonequivalence between the 2 imaging methods; however, the differences are clinically acceptable from the orthodontic point of view. (Am J Orthod Dentofacial Orthop 2013;144:672-81)

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he relationship between symmetry and attractiveness of the face is well documented.1,2 Farkas3 noted the importance of paired and angular measurements in detecting asymmetries as well as quantifying the face. In clinical practice, disharmonies, even if belonging to the borderline values of the normal range statistically, might create visually the impression of moderate disproportions.3

a Resident, Department of Orthodontics and Oral Facial Genetics, School of Dentistry, University of Indiana, Indianapolis, Ind. b Professor, Department of Orthodontics and Oral Facial Genetics, School of Dentistry, University of Indiana, Indianapolis, Ind. c Biostatistician supervisor, Department of Biostatistics, School of Medicine, University of Indiana, Indianapolis, Ind. d Assistant professor, Department of Orthodontics and Oral Facial Genetics, School of Dentistry, University of Indiana, Indianapolis, Ind; lecturer, Department of Orthodontics, Faculty of Dental Medicine, Al-Azhar University, Cairo, Egypt. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Funded by the Craniofacial Complex Center of Indiana University-Purdue University and the Jarabak Endowed Professorship. Address correspondence to: Ahmed A. Ghoneima, Department of Orthodontics and Oral Facial Genetics, Indiana University School of Dentistry, 1121 W Michigan St, Indianapolis, IN 46202; e-mail, aghoneim@iu.edu. Submitted, April 2013; revised and accepted, July 2013. 0889-5406/$36.00 Copyright Ó 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.07.007

Objective evaluation of the soft tissues of the face is integral to effective treatment planning, postoperative assessment, and describing patterns of craniofacial growth and variation.4,5 The bony and dental framework supports the soft tissues of the face, which provides subtle and sometimes glaring information concerning the positioning of the framework. In the face, asymmetry can be produced either by defects of the underlying skeleton that can disrupt identification of the bony landmarks along the facial framework and midaxis of the face, or by disfigurements in the soft-tissue structures affecting the location of the soft-tissue landmarks.3 Facial analysis has rapidly become the determinant of many orthodontic treatment choices.6 Although there are many limitations to what clinicians can do to change the soft tissues with orthodontic treatment, the soft tissues ultimately direct the treatment decisions. Assessing the intricate details of a patient's facial anatomy in 3 dimensions has traditionally been limited to evaluating the patient clinically. New technology has been introduced to evaluate the patient's 3-dimensional (3D) anatomic relationships.7 These advances in imaging have substantially enhanced the clinician's diagnostic ability and, at the same time, obviated the need for exposing patients to extra ionizing radiation in many cases.8

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The hard-tissue reference planes were matched on the soft-tissue CBCT image and the 3dMD photographic image and locked in position (Fig 4).9.) who was making the measurements. Statistical analysis The images in the reliability study were analyzed using intraclass correlation coefficients and Bland-Altman plots to assess intraexaminer repeatability and interexaminer agreement. hard-tissue reference planes were established first on each CBCT image showing the underlying skeletal structures. the study was designed to have 90% power to detect equivalence. and parameters were measured on each CBCT and 3dMD image separately using software measurement tools such as landmarking (soft-tissue landmarks) and calipers (distance and angular measurements) (Fig 5). the coronal plane passed through the most posterior and superior point of the condylar head. The skin segmentation view was further refined by choosing the initial refinement tool that is integrated in the software to remove the noise and excess areas that were not used in measurements (Fig 2).E. Landmarks were identified. They were a convenience sample of trumpet players who consented to participate in a prior study completed by the Department of Orthodontics at the School of Dentistry of Indiana University. The equivalence limits were defined based on the repeatability results for each measurement.) was blinded to the identity of the subjects. Hatfield. The 70 participants consisted of 15 women with a mean age of 22. The 3dMD system was used to capture each subject's 3D facial images. and ranges) were calculated for all measurements from both the 3dMD photographs and the CBCT images. MATERIAL AND METHODS This retrospective study was performed with 70 3dMD images and 70 CBCT scans for the same subjects. The images were coded and randomized. using an equivalence range of 60. The images were taken within 30 minutes apart to minimize softtissue changes. the segmented soft-tissue surface and the 3dMD photographic image were then superimposed by moving the 3dMD image manually onto the screen to coincide with the segmented soft-tissue surface of the CBCT image. standard deviations.4 SD.M. a soft-tissue segmented view of the CBCT data was created by adjusting the threshold and Hounsfield units to the closest soft-tissue segmentation amount (Fig 1). To demonstrate the equivalence of the 2 methods. American Journal of Orthodontics and Dentofacial Orthopedics November 2013  Vol 144  Issue 5 . used for all CBCT scans. and axial) to obtain the most accurate manual alignment between the images. the difference between them must have a 95% confidence interval (CI) contained entirely within the equivalence limits defined for each measurement.3. All images were stored on secure computers in the Craniofacial Complex Center at the School of Dentistry of Indiana University.5-ms capture speed. The translucency of the 3dMD photograph was decreased to visualize the segmented soft-tissue surface data through the 3dMD data (Fig 3). Summary statistics (means. was set with a 13-cm field of view.Metzger et al 673 The aims of this study were to investigate the equivalence of soft-tissue data from 3dMD photographic imaging compared with that produced via soft-tissue segmentation from 3D CBCT images and to determine whether both methods can be used interchangeably and accurately for orthodontic esthetic treatment planning.M. and analyzed using Vultus software (3dMD). All subjects were positioned equidistant from each camera.G.) and compared for validity. For each subject. This process was done on all images in the same way and by the same investigator. After registration and superimposition of the CBCT and 3dMD photographic images.10 The 3dMD photographic images and the segmented softtissue 3D CBCT images were coded and randomized to blind the investigator (T. Measurements on the previous 10 subjects were repeated by a second investigator (A.3 years and 55 men with a mean age of 22. and 0.9-second scanning time. and the primary investigator (T. superimposed. The Hounsfield units value was preset at À999. which was set with a 1. To standardize the position of each set of images.A. and the axial plane passed through porion and orbitale (Frankfort horizontal plane). Using the reference plane tool. Reliability was assessed by measuring the selected parameters of 10 randomly selected subjects. The parameters were selected based on previous studies of soft-tissue landmarks (Table I). This process was performed from 3 planes (sagittal. The i-CAT device (Imaging Sciences International.0 6 2. 8. coronal. Pa). With a sample size of 70 subjects. the landmarks and the linear and angular parameters were identified on both the 3dMD images and the segmented soft-tissue surfaces of the CBCT images. The images were registered. The midsagittal plane ran through nasion-anterior nasal spine-basion.3 voxel scanning resolution. standard errors.E. The differences between the measurements and the ratio of the measurements for the 2 methods were calculated and summarized.1 years.9 6 4.0 in the 3dMD software for skin segmentation and was then adjusted if the segmentation was unsatisfactory. All parameters were measured again by the same investigator 2 weeks later using the same workstation.

Summary statistics for all collected measurements were calculated for both the CBCT images and the 3dMD photographs (Table II). Plane and angle measurements used in the study Parameter Total facial height: N-Pg (mm) Upper facial height: N-Sn (mm) Lower facial height: Sn-Pg (mm) Vermilion height: LS-LI (mm) Mouth width: Ch(R)-Ch(L) (mm) Total facial width: Tr(R)-Tr(L) (mm) Upper lip to E-line: LS to E-line (mm) Lower lip to E-line: LI to E-line (mm) Mandibular position vertically: Point B to axial plane (mm) Maxillary position vertically: Point A to axial plane (mm) Mandibular position AP: Point B to coronal plane (mm) Maxillary position AP: Point A to coronal plane (mm) Mouth symmetry: Ch(R) and Ch(L) to midsagittal plane (mm) Ch(R) and Ch(L) to axial plane (mm) Soft-tissue lip thickness: LS to maxillary central incisor (mm) LI to mandibular central incisor (mm) Eye symmetry: Exoc(R) and Exoc(L) to midsagittal plane (mm) Exoc(R) and Exoc(L) to axial plane (mm) Mandible symmetry: Go(R) and Go(L) to midsagittal plane (mm) Go(R) and Go(L) to axial plane (mm) Facial angle: N-Pn-Pg ( ) Nasofacial angle: Pn-Sn-Pg ( ) Definition Vertical linear measurement of facial dimension as measured from nasion (N) to pogonion (Pg) Vertical linear measurement of upper facial dimension as measured from nasion (N) to subnasale (Sn) Vertical linear measurement of lower facial dimension as measured from subnasale (Sn) to pogonion (Pg) Vertical linear measurement of lips from most prominent point of upper lip or labrale superior (LS) to most prominent point of lower lip or labrale inferior (LI) Transverse linear measurement of mouth width from cheilion right Ch(R) to cheilion left Ch(L) Transverse linear measurement of facial width as measured from tragion right Tr(R) to tragion left Tr(L) Anteroposterior linear position of upper lip (LS) to plane extending from tip of nose to most prominent point of chin (E-line) Anteroposterior linear position of lower lip (LI) to plane extending from tip of nose to most prominent point of chin (E-line) Vertical linear position of the deepest midline concavity on the mandibular symphysis (Point B) to the axial plane Vertical linear position of the deepest midline concavity on the maxilla (Point A) Anteroposterior (AP) linear position of the deepest midline concavity on the mndibular symphysis (Point B) Anteroposterior (AP) linear position of the deepest midline concavity on the maxilla (Point A) Transverse and vertical linear comparison of cheilion right Ch(R) and cheilion left Ch(L) positions AP linear measurement of most prominent point of upper lip (LS) to maxillary central incisor and lower lip (LI) to mandibular central incisor Transverse and vertical linear comparison of exocanthion right (Exoc[R]) and exocanthion left (Exoc[L]) positions Transverse and vertical linear comparison of gonion right (Go[R]) and gonion left (Go[L]) positions Angular measurement of soft-tissue profile measured from nasion (N) to pronasale (Pn) to pogonion (Pg) Angular measurement of soft-tissue profile measured from pronasale (Pn) to subnasale (Sn) to pogonion (Pg) assuming that the true difference between the methods was zero. not all 28 data points were identifiable for all subjects. and eye symmetry (Table III). eye symmetry to the midsagittal plane. Twenty-one of the 28 landmarks were measured on all 3dMD images. soft-tissue lip thickness. Only 2 measurements (eye measures) barely exceeded the arbitrarily selected standard of 3 mm of asymmetry. maxillary position in the anteroposterior direction. All other data points were equivalent based on the mean differences between the 2 methods. November 2013  Vol 144  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics . mouth width. whereas some measurements had lower interrater reliability values (lower facial height.674 Metzger et al Table I. The results were determined to be clinically acceptable at an arbitrary value of 3 mm since interobserver error was less than 3 mm. Intrarater reliability was high for all values. Although 70 3dMD and CBCT images were used in this study. and mandibular symmetry to the midsagittal plane). mouth symmetry to axial plane). and a 2-sided 5% significance level. vermilion height. and 14 of the 28 landmarks were measured on all CBCT images. total facial width. RESULTS The reliability subjects were analyzed using intraclass correlation coefficients and Bland-Altman plots to assess intraexaminer repeatability and interexaminer agreement. Statistically significant differences were reported for the following measurements: vermilion height.

labrale superior. Our study proved some limitations in data points compared with their study. there were areas of nonequivalence. Soft-tissue segmentation process. and ears (vermilion height). eye symmetry in the vertical dimension could have been impacted by the difference in the 2 modalities. In addition.Metzger et al 675 Fig 1. The greatest difference in data was at softtissue pogonion. whereas in the 3dMD photo the eyes were open. Those areas of nonequivalence also represented the lowest agreement ratios in repeatability and agreement testing. the authors used cadavers (in contrast to our study) in which softtissue pull. In some cases. total facial width. Kim et al12 also used cadavers to study the precision and accuracy of facial softtissue measurements using multiplanar reconstructed computed tomography images. matching of the hard-tissue reference planes of living subjects was important for consistency of image alignment. DISCUSSION In this study. and labrale inferior showed the possibility of less predictable landmark identifications because of illdefined lip margins on the soft-tissue segmented CBCT images. a change in the soft-tissue muscle pull could cause a slight change in this landmark vertically that would impact the accuracy of the 3dMD measurements statistically. Although most (21 of 28) soft-tissue landmarks chosen were equivalent based on the mean difference between the 2 methods. mouth symmetry. it might have been caused because the data point was located at the edge of the 3dMD field American Journal of Orthodontics and Dentofacial Orthopedics November 2013  Vol 144  Issue 5 . Measurements including data points cheilion. opening of eyes. soft-tissue lip thickness. the patients had their eyes closed because of the clinical safety protocol. as well as facial hair that caused blurring of landmark margins. In the CBCT scan. eyes. and other issues would not have been apparent.13 Measurements involving tragion might have shown inconsistencies because of the 3dMD camera's inability to capture it in detail. Fourie et al11 reported that the 3D scanning systems were accurate and reliable when compared with direct anthropometric measurements and validated the systems for clinical use. mouth width. Incrapera et al14 concluded that future midtreatment soft-tissue evaluations can be carried out using a noninvasive imaging system such as 3dMD. Although that study proved high levels of accuracy. and eye symmetry. They proved that multiplanar reconstructed computed tomography imaging reconstructed to align with the long axis of the punctures from the skin to the underlying bone is accurate. The areas of nonequivalence generally consisted of measurements involving the mouth.

Alternatively. In a study reviewing the Genex FaceCam system (Genex Technologies. and any change in expression has the potential for adding noise to the image. Wong et al15 found that craniofacial anthropometry using the 3dMD system is valid and reliable compared with direct anthropometry and suggested that digital measurements of prolabial width might require direct marking before imaging to improve identification. We also found differences with this landmark that suggest inconsistent identification because of poorly defined philtral crests. and obscured landmarks caused by the camera flash. At this time.676 Metzger et al Fig 2. The obvious lack of simultaneous capture of images could influence eye or mouth landmarks. however. Md). Although our study shows good to excellent reliability in identification of landmarks without premarking the landmarks. the bizygomatic point can also be used as a valid soft-tissue alternative to tragion with practice in obtaining this landmark. the inability to take simultaneous images is apparent because of physical limitations of the equipment. and only the 180 field of view 3dMD system was used. of view and prone to light distortion. whereas the CBCT scan required 8. Inc.5 ms. problems can arise from this process. Many areas of statistically significant differences in our data involved landmarks near the philtrum or those that might have involved facial hair obstructing landmark identification such as cheilion right and left as well as tragion. The manual superimposition of the 3D images with the Vultus software in our study was based on past November 2013  Vol 144  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics . it was found that multiple captures can be stitched together into 1 composite during postprocessing. facial hair.9 seconds. Identification of tragion might be improved through stitching of lateral and frontal images as well as plotting the soft-tissue bizygomatic point vs tragion if this data point cannot be identified. Captures might not be obtained synchronously. which also lies on the edge of the field of view.16 Our study was retrospective. We could not use stitched imaging to increase the accuracy of tragion. The difference in time could have allowed a slight twitch of an eye or a mouth. Bethesda. The 3dMD photographic images were captured in 1. the lack of statistical equivalence between the landmarks with lower reliability in both imaging modalities indicates the probable influence of these factors. The same reason could explain the inconsistencies we found in softtissue measurements that included tragion. Segmentation after initial refinement. Another factor possibly affecting the equivalency of the measurements is the length of time to record the images.

registration of a 3D stereophotograph on a CBCT image.17 After registration. 3dMD) and their accuracy and found that they are safe and accurate ways of obtaining 3D images of the cranium. Visualization of soft-tissue segmentation through 3dMD.Metzger et al 677 Fig 3. Along with the clinical benefits. similar to our study. Clinicians dealing with the facial region encounter an increasing demand for treatment mainly based on esthetic requests rather than correction of functional problems. placing importance on the soft tissues of the face. the referencebased method was more accurate when different subjects were registered.4 Littlefield et al21 evaluated the development of the 3D imaging systems (laser scanners. Surface-based registrations produced more accurate results than the reference-based method in their study because the registrations were of the same subjects. CCD systems. In our study.17 With surface registration methods. it has significant potential as a research tool for documenting patient history and evaluating treatment. and a covering must be placed on the head during digitization of the image to eliminate problems with hair. it is possible to superimpose 3D textured surface data on reconstructed 3D skin models.18 Image fusion. structured light. They also evaluated the limitations of the software and indicated that current systems cannot capture the intricate details of the ears. research by Maal et al. Maal et al focused on the accuracy of the registration process of the 3D images. objective facial characteristics that are considered by the public as attractive. 3D imaging has a great clinical advantage.19 The boundaries of dental compensation for a jaw discrepancy are established by several aspects of anteroposterior or transverse soft- tissue relationships and functions.1 The paradigm shift in treatment basis also means that many clinicians have started to plan from the external profile. and hard-tissue reference planes were matched between images. a black head scarf was used to cover the subjects' hair. Since soft-tissue data from 3dMD photographic imaging can be considered clinically equivalent to that produced by soft-tissue segmentation from 3D CBCT images.20 Orthodontists and maxillofacial and plastic surgeons should have a deep understanding of those quantifiable. largely to determine the boundaries of orthodontic treatment. the 3dMD system is expected to play an important role in soft-tissue evaluation throughout treatment American Journal of Orthodontics and Dentofacial Orthopedics November 2013  Vol 144  Issue 5 . Although these limitations exist in the software. provides a precise photorealistic digital representation of the patient's face. the images were manually superimposed.

Frontal view. November 2013  Vol 144  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics . B. A. three quarter view showing the soft-tissue landmarks. Reference planes.678 Metzger et al Fig 4. Fig 5.

2 27.4 5.2 18.0 82.1 53.4 49.0 2.9 115.3 52.4 28.9 137.5 3.2 48.5 6.5 7.5 18.1 1.6 44.8 79.8 2.9 39.0 17.5 16.6 77.2 À2.8 121.1 41.0 3.4 6.6 40.3 82.0 À2.2 48.9 2.1 37.7 54.9 16.7 49.0 6.5 18.0 84.8 81.0 2.1 25.7 8.7 59.6 29.9 52.7 95.9 21.6 16.7 6.5 45.3 118.8 68.0 9.2 37.5 51.7 3.2 165.6 3.7 43.0 54.6 44.2 56.9 53.6 American Journal of Orthodontics and Dentofacial Orthopedics November 2013  Vol 144  Issue 5 .9 58.5 89.0 5.7 2.9 131.7 7.9 129.6 113.9 À3.9 13.8 73.9 55.0 129.4 117.2 76.2 78.8 5.9 111.2 57.1 39.9 5.9 30.7 5.6 6.8 11.3 129.4 1.9 6.7 2.2 22.0 36.0 51.9 47.6 17.3 48.5 5.9 5.7 52.6 60.4 2.0 36.7 À2.1 18.8 57.5 51.1 76.0 11.8 17.6 70.6 140.2 50.5 68.4 3.1 11.5 22.1 15.7 59.0 24.9 2.2 22.3 16.1 46.6 6.3 59.4 90.4 115.7 82.0 9.7 20.2 24.9 29.3 39.3 9.2 45.0 3.6 4.1 21.0 146.1 Maximum 132.4 7.6 80.9 5.4 160.9 4.9 2.4 43.7 7.3 7.6 5.8 4.9 50.6 29.4 48.4 3.3 Minimum 94.3 43.7 3.8 68.1 101.3 121.4 4.5 97.7 68.2 79.6 5.7 36.7 29.8 2.4 5.3 2.3 48.7 45.0 47.8 164.0 128.9 98.9 4.8 4.7 3.2 62.0 24.2 64.7 16.1 156.9 102.8 44.7 3.7 30.5 3.2 14.4 76.9 SD 8.8 50.2 12.6 5.9 30.2 63.Metzger et al 679 Table II. Summary Statistics Measurement Total facial height: N-Pg (mm) Upper facial height: N-Sn (mm) Lower facial height: Sn-Pg (mm) Vermilion height: LS-LI (mm) Mouth width: Ch(R)-Ch(L) (mm) Total facial width: Tr(R)-Tr(L) (mm) Upper lip to E-line: LS to E-line (mm) Lower lip to E-line: LI to E-line (mm) Mandibular position vertically: Point B to axial plane (mm) Maxillary position vertically: Point A to axial plane (mm) Mandibular position AP: Point B to coronal line (mm) Maxillary position AP: Point A to coronal line (mm) Mouth symmetry: Ch(R) to midsagittal plane (mm) Mouth symmetry: Ch(L) to midsagittal plane (mm) Mouth symmetry: Ch(R) to axial plane (mm) Mouth symmetry: Ch(L) to axial plane (mm) Soft-tissue lip thickness: LS to maxillary central incisor (mm) Soft-tissue lip thickness: LI to mandibular central incisor (mm) Eye symmetry: Exoc(R) to axial plane (mm) Eye symmetry: Exoc(L) to axial plane (mm) Eye symmetry: Exoc(R) to midsagittal plane (mm) Eye symmetry: Exoc(L) to midsagittal plane (mm) Mandible symmetry: Go(R) to axial plane (mm) Mandible symmetry: Go(L) to axial plane (mm) Mandible symmetry: Go(R) to midsagittal plane (mm) Mandible symmetry: Go(L) to midsagittal plane (mm) Facial angle: N-Pn-Pg ( ) Nasofacial angle: Pn-Sn-Pg ( ) Method 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT Mean 114.9 7.3 10.9 53.1 63.1 61.0 2.8 145.5 53.3 140.8 39.4 7.4 112.5 3.0 24.9 12.2 9.2 138.9 50.6 82.2 39.

0 (À0.20 1.60 1. Equivalence conclusions Within-specimen SD for reliability Measurement Total facial height: N-Pg (mm) Upper facial height: N-Sn (mm) Lower facial height: Sn-Pg (mm) Vermilion height: LS-LI (mm) Mouth width: Ch(R) . 0.7 Y 1. 2. À0. Class II division 1: malocclusion and normal occlusion at rest and on smiling. À0.2) 0.01 1.9 Y 2.4) 2.0 (0.9 Y 1.6 (0. 2008. 9.1. Richmond S. Craniofacial imaging in orthodontics: historical perspective. Mich. 1.3 (0. Sarver DM.3.98 0. 0. 1.5) 1. Soft-tissue facial characteristics of attractive and normal adolescent boys and girls. November 2013  Vol 144  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics . Hatcher D.0 N 2.47 1.3 Y 1.4.15 1. Babbush CA. Weinberg SM.32 0. 1.4 Y 2.0) 0. and late mixed dentition phases. current status. Farkas L.3.5 (À0.4 (0. 19-54.39 0.5.57 1.5 Y 2.6. future midcourse evaluations of soft tissues could be made accurately with the 3dMD system.13 1. Grandi G.8.3) 0. 3.6. Nakasima A.15 0.3.14 0.9 Y 1.74 1.04 1.9) À0.8) 0. Anthropometry of the head and face.2) 0.59 1.72 0. Angle Orthod 2008.2) À0.02 1. Hara A.44 0.17:477-83. 3. Anthropometric precision and accuracy of digital three-dimensional photogrammetry: comparing the Genex and 3dMD imaging systems with one another and with direct anthropometry.42 0. Mean difference (95% CI) 0.26 1.3. J Craniofac Surg 2006.0 N 1. Islam R. 5.1.0 Y 2. Ferrario VF.1.8 (1.12 1.2.1 Y 2.0 (0.5 (0. 1994.1 Y 2.3. Naidoo S. 7. À0.7.8 Y 1.4) À0. 0. 0.1 (2. 1. 1.83 0. Frontiers of dental and facial esthetics. Ann Arbor.36 1.82 0.7. no.20 1.1 (À1. 0. 1.5) 0. Three-dimensional evaluation of facial asymmetry in association with unilateral functional crossbite in the primary.4 (0. Angle Orthod 2013.6) À0.4 Y 2.93 1. St Louis: Mosby. 4.97 1.5 Y to reduce the need for exposing the patient to extra radiation. New York: Raven Press. 3.0 (À0.2 (2. Trosien A.02 1.50 0.52 0.0 Y 3.6) 3.7 Y 1.0 (0.52 1. p. 3.23 Equivalence range defined Equivalent based using 23withinon difference specimen SD between methods 2.23 1.7. REFERENCES 1.65 1.0. Three-dimensional diagnosis and treatment planning: the use of 3D facial imaging and 3D cone beam CT in orthodontics and dentistry.82 1.03 1. Lip morphological changes in orthodontic treatment. Tartaglia GM. N. and future developments. Angle Orthod 1999. Mosby's dental dictionary.1) 1.2) 1.4 Y 3. providing an alternative method for soft-tissue evaluation with no radiation exposure.2 N 2. The face as the determinant of treatment choice.6. Govier DP.7) 0. Since it is difficult to determine the soft tissues in CBCT images. 2.25 0.2) 2.1 (0.4 (À0.1 (À0.66 0. Although a few landmarks showed statistically significant differences.0. Kitahara T. 3.0.2.3 N 0. Kane AA.Ch(L) (mm) Total facial width: Tr(R)-Tr(L) (mm) Upper lip to E-line: LS to E-line (mm) Lower lip to E-line: LI to E-line (mm) Mandibular position vertically: Point B to axial plane (mm) Maxillary position vertically: Point A to axial plane (mm) Mandibular position AP: Point B to coronal line (mm) Maxillary position AP: Point A to coronal line (mm) Mouth symmetry: Ch(R) to midsagittal plane (mm) Mouth symmetry: Ch(L) to midsagittal plane (mm) Mouth symmetry: Ch(R) to axial plane (mm) Mouth symmetry: Ch(L) to axial plane (mm) Soft-tissue lip thickness: LS maxillary central incisor (mm) Soft-tissue lip thickness: LI to mandibular central incisor (mm) Eye symmetry: Exoc(R) to axial plane (mm) Eye symmetry: Exoc(L) to axial plane (mm) Eye symmetry: Exoc(R) to midsagittal plane (mm) Eye symmetry: Exoc(L) to midsagittal plane (mm) Mandible symmetry: Go(R) to axial plane (mm) Mandible symmetry: Go(L) to axial plane (mm) Mandible symmetry: Go(R) to midsagittal plane (mm) Mandible symmetry: Go(L) to midsagittal plane (mm) Facial angle: N-Pn-Pg ( ) Nasofacial angle: Pn-Sn-Pg ( ) Y.9 (0. À0. these are clinically acceptable from the orthodontic point of view.18 1. Quintero JC.91 1.0 N 1.71 1. Kelly KA.1) 0.8 Y 2.7 (1. Perinetti G. 1. 2.5 N 1. 1.3) 1.8) 3dMD 1.0 (0.27 0. Sforza C. 1.7 Y 2.2.83:253-8.7. 0. editors.22 1.69 1.78:799-807. Angle Orthod 2009.27 1. Primozic J. D'Alessio R. 0.06 1.90 0. CONCLUSIONS The evaluated systems (3dMD and segmented softtissue images from CBCT) can be used interchangeably for orthodontic treatment planning because both imaging modalities provide similar representations of the soft-tissue anatomy.45 0. In: McNamara J.5) 1.0) À1.6 (0.08 1.1) 1.69:491-506.4 (À0.0 (0.09 1.2 (1. early. 6. Yes.6.1.75 0.8.680 Metzger et al Table III.10 CBCT 1.8) À0. Laino A.18 1.8 Y 0. À0.2 (1.4) 1.10 0.2) 1.7 (À1.2) 3.87 0. Naher L. Aust Dent Pract 2007:102-13. 8.0 N 1.6 (0. Martin RA.79:256-64. Harrell W Jr. 2001. Kapila S.4) 0.5. Ovsenik M.3 Y 2. Marazita ML.01 0.6 Y 1. 0.

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