ORIGINAL ARTICLE

Comparison between traditional 2-dimensional

cephalometry and a 3-dimensional approach on
human dry skulls
Gregory L. Adams, DDS, MS,a Stuart A. Gansky, DrPH,b Arthur J. Miller, PhD,a William E. Harrell, Jr, DMD,c
and David C. Hatcher, DDS, MSc, MRCD(c)d
San Francisco, Calif, Alexander City, Ala, and Sacramento, Calif

The cephalogram is the standard used by orthodontists to assess skeletal, dental, and soft tissue
relationships. This approach, however, is based on 2-dimensional (2D) views used to analyze 3-dimensional
(3D) objects. The purpose of this project was to evaluate and compare a 3D imaging system and traditional
2D cephalometry for accuracy in recording the anatomical truth as defined by physical measurements with
a calibrated caliper. Thirteen skeletal landmarks were located by both radiographic methods on 9 dry human
skulls. Intraclass correlation (0.995), variance (0.054 mm2), and standard deviation (SD) (0.237 mm) were
averaged over 76 measurements and derived from precision calipers to establish these physical measure-
ments as a reliable gold standard to make comparisons of the 2D and 3D radiographic methods. The results
showed great variability of the 2D from the gold standard, with the range varying from ⫺17.68 mm
(underestimation of Gn-Zyg R) to ⫹15.52 mm (overestimation of Zyg L-Zyg R). In contrast, the 3D method
(Sculptor, Glendora, Calif) indicated a range of the SD from ⫺3.99 (underestimation) mm to ⫹2.96 mm
(overestimation). The 3D evaluation was much more precise, within approximately 1 mm of the gold standard.
These results indicate that, when the actual distance is measured on a human skull in its true dimensions of
3D space, the Sculptor program, by using a 3D method, is more precise and 4 to 5 times more accurate than
the 2D approach. Evaluating distances in 3D space with a 2D image grossly exaggerates the true measure
and offers a distorted view of craniofacial growth. There is an inherent problem of representing a linear
measure occupying a 3D space with a 2D image. (Am J Orthod Dentofacial Orthop 2004;126:397-409)

ephalometry was defined by Moyers1 as a

C
radiographic technique for abstracting the hu-
man head into a measurable geometric scheme.
Cephalometric radiography is used to describe the
morphology and growth of the craniofacial skeleton,
predict growth, plan treatment, and evaluate treatment
results. Most of these tasks require identifying specific
landmarks and calculating various angular and linear
variables. Two types of errors occur with this ap-
a
Division of Orthodontics, Department of Growth and Development, Univer-
sity of California at San Francisco.
b
Division of Oral Epidemiology and Dental Public Health, Department of
Preventive and Restorative Dental Sciences, Center for Health and Community,
University of California at San Francisco, San Francisco, Calif.
c
Private practice, Alexander City, Ala.
d
Owner, Diagnostic Digital Imaging, Sacramento, Calif.
William E. Harrell, Jr, is cofounder and chairman of the board of Acuscape
International, Inc, and David C. Hatcher is a key Acuscape contributor.
Reprint requests to: Dr A. J. Miller, Division of Orthodontics, Department of
Growth and Development, School of Dentistry, University of California at San
Francisco, Dental Clinics Building, 707 Parnassus St, San Francisco, CA
94143-0438; e-mail, amiller@itsa.ucsf.edu.
Submitted, February 2003; revised and accepted, March 2004.
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.03.023
proach— errors of projection and errors of identifica-
tion.2
Errors of projection are caused because the head-
film is a 2-dimensional (2D) representation of a 3-di-
mensional (3D) object. X-ray beams are nonparallel
and originate from a small source, leading to radio-
graphs that are imperfect enlargements affected by the
distances between the focus, the object, and the film.3-7
Landmarks and structures not situated in the midsagittal
plane are usually bilateral, unfortunately giving a dual
image on the radiograph. Bilateral structures in the
symmetric head do not superimpose on the lateral
cephalogram, because the fan of the x-ray beam ex-
pands as it passes through the head, causing a diver-
gence between the images of all bilateral structures.
Misalignment of the cephalostat and rotation of the
patient’s head in the cephalostat in any plane will also
induce errors of projection.
Errors of identification are the errors of identifying
specific landmarks on the headfilms and are considered
by many investigators as the major sources of error in
cephalometrics.8-11 Several factors are involved and
include the quality of the radiographic image, the
precision of landmark definition, the reproducibility of
397
398 Adams et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

Table I. Landmarks, abbreviations, and operational definitions for 9 radiopaque markers on human skulls
Abbreviation Landmark Operational definition

S Sella Point representing midpoint of pituitary fossa on skull

Na Nasion Most anterior point of frontonasal suture in median plane
A A Point Deepest midline concavity on maxilla between anterior nasal spine and prosthion
B B Point Deepest midline concavity on mandibular symphysis between pogonion and infradentale
Gn Gnathion Most anteroinferior point on symphysis of chin
Zyg R Zygomaticotemporal - right Point of junction between right zygomatic and right suture temporal bone
Zyg L Zygomaticotemporal - left Point of junction between left zygomatic and left suture temporal bone
Go R Gonion - right Point of intersection between right ramal plane and right mandibular plane
Go L Gonion - left Point of intersection between left ramal plane and left mandibular plane
Co R Condylion - right Most central point of dorsal surface of right condylar head
Co L Condylion - left Most central point of dorsal surface of left condylar head
ZMX R Zygomaxillary suture - right Central point of right zygomatic suture
ZMX L Zygomaxillary suture - left Central point of left zygomatic suture

the landmark location, the operator, and the registration
procedure. The magnitude of error varies greatly from
landmark to landmark and is usually an ellipse or ovoid
envelope of error. The major problem is that such errors
lead to missing subtle changes and allow only the
grossest changes to be observed clearly.
Broadbent’s introduction of the cephalostat stressed
the importance of using and coordinating both the
lateral and frontal headfilms to define the craniofacial
form.12 Although the method is sound, it has often been
reported as difficult to apply and yields less accurate
measurements than true anatomic values.13 In recent
years, computed tomography (CT) has provided 3D
reconstruction of the entire craniofacial skeleton14-17
from axial slices allowing methods to evaluate all
internal structures including the muscles.18 CT pro-
vides a 3D method to assess some of the same measures
as the 2D cephalogram and evaluate asymmetrical
mandibles.19,20 Magnetic resonance imaging recon-
structed into 3D forms might provide a relatively
accurate method to effectively determine growth and
change, but it has not been studied. Unfortunately, both
methods are too expensive and have limited availability
to be used consistently by practicing orthodontists.
However, the conical x-ray approach, which effectively
offers 3D reconstruction and equipment that is much
more affordable for a radiographic laboratory, is now a
reality.21
The potential tools that can provide 3D evaluation
of a patient seeking orthodontic treatment have been
used in stereophotogrammetry.22,23 Stereophotogram-
metry is a technique developed by civil engineers to
measure 3D relationships of objects and terrains. A
second technique that complements this approach has
been the “bundle adjustment method.” This method
self-calibrates the system, by using many measurement
points simultaneously, to calculate the imaging device
position and the desired 3D point coordinates. Re-
cently, a methodology for identifying landmarks in
calibrated and digitized x-rays and optical images
(Acuscape and Sculptor, Glendora, Calif) has been
under development and will soon be commercially
available.24,25 In this study, we used this new program
and a traditional 2D evaluation to evaluate 9 dry skulls.
These methods are compared to measures on skulls in
which the landmarks are located by external markers,
and the actual linear measures between 2 points (eg,
condyle to symphysis) are made externally with a
precision caliper. Earlier studies have evaluated the
human skull with a 3D digitizing system and compared
that to physical caliper measures.26 Other investigators
have evaluated skulls using CT but often only with the
transverse image, and not with a 3D reconstruction, or
not with an interest in orthodontic landmarks but with
a physical anthropological focus.27-32 Some recent
studies have compared cephalometric radiographs or
CT images of skulls to physical measures. Those
studies indicated differences between the 2D cephalo-
metric radiographic technique and the gold standard33
but relatively good agreement between the 3D CT
image and the actual measures.34-39 One study com-
pared the traditional 2D cephalometric measures of 9
dry human skulls to the same measures done in 3D CT
images, but only in terms of reliability.40 The latest
approaches in 3D cephalometry have applied a matrix
transformation of the 3D coordinate system by using
CT for evaluating human subjects or by applying a grid
to 3D images.41,42
MATERIAL AND METHODS
Nine undocumented dry human skulls were ob-
tained from the Anatomy Department at the University
of California at San Francisco. Intact skulls of variable
morphology were selected. Radiopaque Beekley spots
American Journal of Orthodontics and Dentofacial Orthopedics Adams et al 399
Volume 126, Number 4

Table II. Radiographic image used to identify radiopaque landmarks and linear measures from these landmarks on
skulls
S Na A B Gn ZMX R Zyg R Co R Go R ZMX L Zyg L Co L

Go L Frontal Lateral Lateral Lateral Lateral Frontal Frontal Frontal Frontal Lateral Lateral Lateral
Co L Frontal Lateral Lateral Lateral Lateral Frontal Frontal Frontal Frontal Lateral Lateral
Zyg L Frontal Frontal Frontal Frontal Lateral Frontal Frontal Frontal Frontal Lateral
ZMX L Frontal Frontal Frontal Lateral Lateral Frontal Frontal Frontal Frontal
Go R Frontal Lateral Lateral Lateral Lateral Lateral Lateral Lateral
Co R Frontal Lateral Lateral Lateral Lateral Lateral Lateral
Zyg R Frontal Frontal Frontal Frontal Lateral Lateral
ZMX R Frontal Frontal Frontal Lateral Lateral
Gn Frontal Lateral Lateral Lateral
B Lateral Lateral Lateral
A Lateral Lateral
Na Lateral

(Beekley Corp, Bristol, Conn) were placed on 13
skeletal landmarks (Table I) as targets for both physical
and radiographic measurements. The targets were lo-
cated based on criteria commonly used in 2D cephalo-
metrics and represented midsagittal and bilateral land-
marks.
The physical distance between landmarks was de-
termined by manual measurement with digital calipers
with a resolution of 0.03 mm (Pro Quality Precision
Dial Caliper, LS Starrett, Athol, Mass). To measure the
error of the method, 3 skulls were selected for 2
additional measurement sessions. The mean distances,
standard deviations, and variances were evaluated for
76 measurements to determine intraoperator reliability.
Reliability (intraclass correlation) was calculated from
the sums of squares in a 2-way analysis of variance
(ANOVA) test.
A special proprietary calibration framework
(Acuscape, Glendora, Calif) was placed on the skull for
the imaging sessions for taking x-rays. The framework
included a headpiece with previously surveyed ra-
diopaque metal bearings. Each skull was placed in a
cephalostat, and 3 images were acquired: standard
lateral (90°), frontal (0°), and oblique (45°). The
standard lateral projections oriented the midsagittal
plane parallel to the film. For frontal projections, the
midsagittal plane was set perpendicular to the film.
Care was taken to avoid changes in the orientation of
the calibrated framework. The most appropriate radio-
graphic projection for a given measurement was chosen
(Table II).
The films were scanned with a flatbed scanner
(ScanMaker 9600XL, Microtek, Carson, Calif) cali-
brated to determine precise pixels/mm in the horizontal
(x) and vertical (y) directions. A transparency adapter
was used, and the scanner was set at a resolution of 150
dots per inch. The next procedure established all
images into a 3D matrix to obtain a true Cartesian space
(x, y, z) reference system assigned to the patient. This
calibration began with imaging the calibration frame
and the skull in the same field of view from 2 or more
points of view. The locations of the bearings in the
framework were known and used to assign a reference
system to the calibration frame. The unknowns in-
cluded the skull and the source reference system. To
compute the location of the source (7 degrees of
freedom [DF]: x ⫽ width, y ⫽ height, z ⫽ depth, yaw,
pitch, roll, and focal length), the image sets are placed
into a 3D matrix. The reference system from the
calibration frame is then set or transmitted to the skull.
When the known geometry of calibration markers is
fitted to the image of the calibration frame, there is a
geometric transformation of the known geometry of the
calibration markers. This transformation is the key to
mathematically locating the source with 7 DF. The next
geometric transformation locates the source relative to
the calibration frame with 7 DF and is repeated for all
images. After this calibration, all images have been
placed into the same 3D matrix with the calibrated
frame reference. The reference system can then be
adjusted and set to the skull anatomy to become the
“skull-specific reference.” This skull- or patient-spe-
cific reference system will apply to all anatomy in the
3D space that is represented (Fig 1).
The 3 radiographic images represent 3 cephalomet-
ric points of view and locations of the 3 sources. The
resultant images are merged into the same 3D matrix,
and landmarks are located on the images from 2 or
more different points of view. Triangulation mathemat-
ical calculations locate and record each landmark in
space (x, y, z) with the skull or patient reference
system.
Locating a landmark from 2 views will lead to an
error envelope around the true anatomic landmark (Fig
400 Adams et al
Fig 1. External reference system (blue box) becomes
associated with source (head) and calibration frame (not
shown but appears as multiple points across forehead).
A, Source (patient’s head) located with 7 DF (x, y, z,
yaw, pitch, roll, focal length) relative to calibration frame
(not shown) by taking x-ray or photograph of patient. B,
When known geometry of calibration markers is fitted to
image of calibration frame, geometric transformation of
virtual frame occurs. Geometric transformation then
locates source relative to calibration frame so that all
images are placed into 3D matrix. C, Patient’s specific
reference system will apply to all anatomy in 3D space.
2). In an orthogonal view, the error envelope is circular.
In a coplanar view, the error margin perpendicular to
the beam angle reduces, while the error envelope
increases in the direction parallel to the beam angle.
The use of 3 planes of view reduces the error envelope
to the best or smallest of all 3 points of view.
During a Sculptor session, the 3D distance from the
American Journal of Orthodontics and Dentofacial Orthopedics
October 2004
Fig 2. Changing from 2 to 3 views to locate anatomic
landmark (black dot) in 3D space affects error envelope
(outer line as circle or other shape).
first point (x1, y1, z1) to the second point (x2, y2, z2)
is registered as an identified landmark in the program.
The notation (x1, y1, z1) represents values in 3D space.
All measurements are then downloaded from Sculptor
into a spreadsheet for statistical analysis.
A 2-way ANOVA without replication was per-
formed to evaluate the similarity of the 3 samples
separately (physical gold standard, conventional 2D,
and Sculptor 3D), resulting in intraclass correlations
(ICC) for each measure. The following equation was
used:
ICC ⫽ MSsubject ⫺ MSerror/MSsubject ⫹ 共r ⫹ 1兲 MSerror
where MSsubject is the mean square of the skulls from
the ANOVA, MSerror is the mean square error from the
ANOVA, and r is the number of replicates.43
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 126, Number 4
Fig 3. Bland-Altman plot for measurement Go L-Go R. Thickest line (black) represents absolute
measure for that skull for that measurement set at 0. Mean (red dotted) and 2 SD (red solid) for
conventional 2D cephalometric measurement, and mean (blue dotted) and 2 SD (blue solid) for 3D
Sculptor measurement are shown.
The hypothesis was that the identification of land-
marks and linear measurements, by using 3 planes of
space derived from 3 separate full-head x-rays taken at
different angles on dry human skulls with the Sculptor
system, would be closer in accuracy to the gold
standard reference of physical measurements than the
traditional 2D method. First, the differences in sample
means and standard error of the difference in sample
means were obtained for each measurement pair. Be-
cause the ICC and variance indicated that the physical
measurements were highly reliable, the paired t test was
used to assess the difference between Sculptor and the
conventional 2D measurement system.43 Second, a
modified Bland-Altman method44 was applied, graph-
ing the differences between physical (gold standard)
and 2D and 3D measurements (y-axis) versus physical
measurement (x-axis). This method illustrates the mag-
nitude of the differences (accuracy, bias) from anatom-
ical truth and the distribution of points (precision,
variability) of the measurement variables (Fig 3). The
differences of the 2D cephalometric measures and the
3D Sculptor measures from the physical measures are
shown as individual points compared with the physical
measurement for that skull. The mean ⫾ 2 SD is shown
for the 9 measures from the 9 skulls for the 2D
Adams et al 401
cephalometric measures and then for the 3D Sculptor
measures. In this example, all points were within the 2
SD bounds for both the 2D and 3D methods.
RESULTS
Repeated measures from the sums of squares in a
2-way ANOVA without replication indicated excellent
reliability with a mean ICC of 0.995, with all 63
measurable pairs ⱖ 0.972 for the physical measure-
ments (Table III). This gives a mathematical value of
the similarity between measurements; this reflects the
usefulness of this model to serve as a reference gold
standard by which the remaining experiments can be
completed.43 Values near 0 (or negative) indicate poor
reliability; values close to 1 indicate high reliability.
The mean value of 0.995 indicated high reliability of
the physical measures, as they were repeated on the
landmarks and the measures among the landmarks.
Two measures (S-Gn, S-B) were not completed be-
cause the anatomy of the skulls prevented using the
physical caliper. In comparison, the conventional 2D
method also indicated a high reproducibility margin
(mean ICC: 0.983) as did the 3D evaluation (mean ICC:
0.998).
In comparing each skull measure between the
402 Adams et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

Table III. Intraclass correlation values for physical measurements

S Na A B Gn ZMX R Zyg R Co R Go R ZMX L Zyg L Co L

Go L 0.998 0.997 0.996 0.998 0.998 0.999 0.999 0.997 0.999 0.998 0.996 0.972
Co L 0.999 0.997 0.998 0.996 0.996 0.999 0.999 0.999 0.999 0.992 0.994
Zyg L 0.997 0.999 0.994 0.999 0.999 0.999 0.999 0.999 0.999 0.996
ZMX L 0.999 0.997 0.995 0.987 0.999 0.999 0.999 0.999 0.999
Go R 0.994 0.998 0.997 0.999 0.998 0.999 0.999 0.987
Co R 0.998 0.992 0.992 0.998 0.999 0.996 0.994
Zyg R 0.982 0.976 0.992 0.983 0.992 0.972
ZMX R 0.998 0.999 0.997 0.995 0.997
Gn cnm 0.999 0.995 0.999
B cnm 0.998 0.984
A 0.997 0.997
Na 0.998

cnm, Could not be measured.

conventional 2D approach and the physical measure-
ments, the conventional approach ranged from under-
estimating (Gn-Zyg R; ⫺17.68 mm) to overestimating
(Zyg L-Zyg R; ⫹15.52 mm) the true values of the gold
standard. The paired t test indicated that 70 of the 76
measures were significantly different from the physical
measurements at ␣ ⫽ 0.05 (Table IV). By chance
alone, only 3 or 4 significant measurements were
expected. Five of the 6 measurements that did not
indicate a significant difference have a coefficient of
variation (SD/mean) greater than 1, indicating that the
SD is greater than the mean, exhibiting excessive
variability. Ranking the measurements according to
mean difference (Table V) showed a pattern that
depended on several factors (lateral position of the
anatomical point, plane of measure in the frontal
cephalometric image). The 2D cephalometric measures
of lateral anatomical points in the frontal plane dem-
onstrated some of the greatest differences from the
physical measure. Measures with 1 point lateral (Zyg,
Go, Co) and the second near the midline (Na, Gn) had
much larger differences from the physical measure with
the 2D cephalometric analysis.
The Bland-Altman plot—illustrating the magni-
tude of the difference in the anatomic truth and
distribution of points—showed low precision (high
variability) for the conventional 2D method and low
accuracy (high bias) compared with the physical
measurements (Figs 4 and 5). Some plots for indi-
vidual measures showed that the 2D method had high
variability and high bias, sometimes overestimating
and sometimes underestimating. The measurement
points were not in a pattern (linear or quadratic
errors) in each plot or between plots, signifying no
relationship between actual length of the measure-
ment and mean difference between 2D measures and
the physical measures. Some 2D cephalometric mea-
sures significantly varied from the physical measures
(Table IV, Fig 4; Na-B). Other 2D cephalometric
measures were relatively near the physical measures
(Fig 5; Gn-Co L). Some 2D cephalometric measures
also had much more range in their differences from
their physical measures, suggesting that this measure
and its orientation in space could markedly affect the
2D cephalometric image and length more than would
be expected (Fig 6; A point-Co L).
In comparing each measure from the 3D approach
with the physical measurements, the 3D approach had a
much smaller range from underestimating (A-Co R;
⫺3.99 mm) to overestimating (A-ZMX; ⫹2.96 mm).
Comparison with the paired t test indicated that 67 of
the 76 measures were significantly different between
the 3D and physical measures (Table VI). Of the 9
measures that did not differ significantly, only 1 had a
coefficient of variation greater than 1, resulting in
excessive variation in the measure. The mean 3D
differences from true for 75 of 76 measures were
negative. Ranking the measurements according to mean
difference showed that measures from a midline point
to a much more lateral anatomical point were more
variable when the lateral point was to the right (Table
VII).
The Bland-Altman plots showed high precision
with the Sculptor method, yet with some minor inac-
curacies with a mean of ⫺1.05 ⫾ 0.54 mm difference
from the physical measures indicating slight underesti-
mation of the anatomical truth (Fig 7). The mean
difference ranged from ⫺2.49 (Na-Co R) to ⫹0.30 mm
(A-ZMX L); 75 of 76 mean differences were negative
(67 were statistically significant), and the 1 positive
mean difference was not statistically significant from 0.
The Sculptor 3D approach was usually 4 or 5 times
closer to the physical measures than the conventional
2D approach (Table VIII) and demonstrated much less
American Journal of Orthodontics and Dentofacial Orthopedics Adams et al 403
Volume 126, Number 4

Table IV.76 measures that compared conventional 2D Table IV. continued

cephalographic measures to gold standard of physical
measurements Mean difference SD Minimum Maximum
Measurement (mm) (mm) (mm) (mm)
Mean difference SD Minimum Maximum
Measurement (mm) (mm) (mm) (mm) ZMX R-Zyg R ⫺2.38 1.93 ⫺6.32 0.41
Zyg R-Go L 6.93 3.48 1.84 13.32
S-Go L 5.50 2.58 0.16 8.77 Zyg R-Co L 7.35 2.43 4.40 12.08
S-Co L 4.66 0.93 3.55 5.84 Zyg R-Zyg L 13.61 2.10 8.33 15.52
S-Zyg L 2.78 2.06 ⫺1.78 4.77 Zyg R-ZMX L 10.79 1.22 9.18 12.57
S-ZMX L ⫺10.97 2.83 ⫺14.27 ⫺6.32 Zyg R-Go R 5.32 0.91 4.24 6.73
S-Go R 8.36 1.65 6.05 10.92 Zyg R-Co R 3.83 0.44 3.05 4.65
S-Co R 4.93 0.96 4.02 5.93 Co R-Go L 10.81 1.29 9.32 12.86
S-Zyg R 4.00 2.60 1.17 10.07 Co R-Co L 10.75 0.91 9.27 12.35
S-ZMX R ⫺11.24 3.91 ⫺16.84 ⫺4.33 Co R-Zyg L 8.44 0.95 7.09 9.91
S-Gn cnm Co R-ZMX L ⫺2.60 2.17 ⫺5.26 1.54
S-B cnm Co R-Go R 4.24 1.49 2.57 5.90
S-A 7.84 1.15 6.50 9.46 Go R-Go L 9.01 0.97 7.57 10.14
S-Na 6.22 0.84 5.51 7.41 Go R-Co L 9.48 5.22 ⫺2.66 14.42
Na-Go L ⫺0.54 1.81* ⫺3.00 1.92 Go R-Zyg L 9.01 2.36 4.45 12.30
Na-Co L ⫺8.36 2.23 ⫺11.67 ⫺5.32 Go R-ZMX L ⫺2.19 3.66* ⫺6.39 5.68
Na-Zyg L ⫺4.49 1.93 ⫺7.15 ⫺1.32 ZMX L-Go L 3.85 0.82 2.26 4.82
Na-ZMX L 5.42 1.44 3.47 8.65 ZMX L-Co L 2.26 1.27 0.56 3.98
Na-Go R 1.20 1.60* ⫺1.55 2.69 ZMX L-Zyg L ⫺2.04 1.46 ⫺4.24 0.07
Na-Co R ⫺11.38 2.19 ⫺15.50 ⫺7.94 Zyg L-Go L 1.60 1.28 ⫺0.73 3.40
Na-Zyg R ⫺3.09 3.10* ⫺9.48 1.29 Zyg L-Co L 1.17 0.66 0.18 2.08
Na-ZMX R 5.32 1.82 1.32 6.97 Co L-Go L 2.11 1.19 ⫺0.46 3.26
Na-Gn 9.82 0.51 8.88 10.40
Na-B 8.32 0.32 7.73 8.74 Positive mean values indicate differences (biases) from physical caliper
Na-A 4.99 0.25 4.70 5.35 (gold standard), measure overestimate; negative mean values indicate
A-Go L ⫺3.96 1.47 ⫺6.37 ⫺2.05 differences (biases) from underestimate; cnm, could not be measured.
A-Co L ⫺7.39 3.42 ⫺13.20 ⫺3.72 *Coefficient of variation (SD/mean) ⬎1; all were significantly different
A-Zyg L ⫺5.04 2.49 ⫺9.58 ⫺1.46 from 0 (biased) with paired t test (P ⬍ .05) except Na-Go L/R, B-Co L,
A-ZMX L 3.76 1.70 0.83 6.41 Gn-Co L, ZMX R-Go L, ZMX L-Go R.
A-Go R ⫺6.25 2.70 ⫺11.83 ⫺3.60
A-Co R ⫺10.80 1.79 ⫺12.47 ⫺7.58
A-Zyg R ⫺3.20 3.60* ⫺8.88 2.11 variability (mean SD: 0.54 mm) than the 2D (mean SD:
A-ZMX R 3.89 1.86 1.14 6.95
A-Gn 4.63 0.62 3.51 5.49 6.94 mm).
A-B 3.11 0.55 1.94 3.69
B-Go L ⫺5.28 2.60 ⫺8.21 ⫺1.22 DISCUSSION
B-Co L ⫺1.90 2.50* ⫺3.98 3.84 This is the first study that has compared physical
B-Zyg L 4.31 4.78* ⫺5.45 10.22 measurements of the human skull to both the standard
B-ZMX L ⫺6.83 2.76 ⫺10.79 ⫺2.24
B-Go R ⫺9.01 2.74 ⫺12.34 ⫺4.35 2D cephalometric analysis and a newly developed 3D
B-Co R ⫺8.75 2.83 ⫺13.22 ⫺3.45 system that also uses radiographs. The landmarks were
B-Zyg R 5.81 5.04 ⫺6.00 10.29 chosen by an expert craniofacial radiologist (D.C.H.),
B-ZMX R ⫺10.09 2.44 ⫺13.89 ⫺6.21 who has spent over 20 years evaluating x-rays, CT, and
B-Gn 1.54 0.36 0.93 2.02 magnetic resonance imaging of the head. An additional
Gn-Go L ⫺4.32 2.51 ⫺7.60 ⫺0.53
Gn-Co L ⫺2.31 3.04* ⫺7.38 1.15 strength of the project is that this investigator chose
Gn-Zyg L ⫺7.36 2.55 ⫺11.79 ⫺4.69 landmarks based on years of determining information
Gn-ZMX L ⫺3.17 2.46 ⫺6.67 0.59 from radiographs. By identifying each landmark di-
Gn-Go R ⫺10.19 3.56 ⫺15.52 ⫺4.81 rectly on the skull, errors of identification were elimi-
Gn-Co R ⫺6.25 2.90 ⫺11.17 ⫺1.21 nated. By applying physical measurements to these
Gn-Zyg R ⫺12.13 2.65 ⫺17.68 ⫺8.58
Gn-ZMX R ⫺6.12 2.68 ⫺11.23 ⫺2.02 known and marked sites, the actual anatomical dis-
ZMX R-Go L ⫺3.59 6.37* ⫺10.71 7.29 tances could be established as a gold standard with
ZMX R-Co L ⫺5.23 3.01 ⫺10.07 ⫺1.10 which the 2D and the 3D evaluations of the radiographs
ZMX R-Zyg L 9.80 1.40 7.90 11.70 could be compared to determine their true accuracy.
ZMX R-ZMX L 12.15 1.16 9.38 13.60 In the Acuscape program, the most important aspect
ZMX R-Go R 7.97 1.02 6.83 9.89
ZMX R-Co R 4.78 1.70 1.88 7.21
to enhance its optimal accuracy is the calibration
framework. It must not move on the subject during the
404 Adams et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

Table V. Example of 25 measures that compared greatest differences when compared with the true phys-
conventional 2D cephalographic measures to physical ical measures. This would be expected in the lateral 2D
measures ranked by largest to smallest mean differences cephalometric image, but the great differences were
Mean particularly evident in measures from the frontal 2D
difference SD image (eg, Zyg L-Zyg R, Co L-Co R). These large
Measurement (mm) (mm) differences can be explained because the actual plane
Zyg L-Zyg R 13.61 2.10 for each measure was not at the midpoint of the frontal
Gn-Zyg R 12.13 2.65 plane projected for the 2D x-ray image. When the range
Na-Co R 11.38 2.19 of measures was considered instead of the difference
Co L-Co R 10.75 0.91 from the physical measure, some 2D cephalometric
Gn-Go R 10.19 3.56
measures had much greater variation (eg, Na-Zyg R),
Na-Gn 9.82 0.51
B-Go R 9.01 2.74 suggesting that a particular measure and its orientation
Go L-Go R 9.01 0.97 to the film could be much more effective in providing
B-Co R 8.75 2.83 a spurious length measurement. The concept of linear
Na-Co L 8.36 2.23 projection transformation is important to deciphering
Na-B 8.32 0.32
why 2D cephalometric measures can be erroneous.45,46
Gn-Zyg L 7.36 2.55
Gn-Co R 6.25 2.90 The Sculptor 3D approach had 2 key advantages.
S-Na 6.22 0.84 First, it had high precision with a greatly reduced bias
B-Go L 5.28 2.60 to the gold standard. The consistency of the bias
Na-A 4.99 0.25 (slightly negative) suggests that engineering the soft-
A-Gn 4.63 0.62
ware or calibration framework, or a simple mathemat-
Na-Zyg L 4.49 1.93
Gn-Go L 4.32 2.51 ical correction factor, can correct the bias. Second, the
A-B 3.11 0.55 Sculptor 3D approach had much less variability in its
Na-Zyg R 3.09 3.10 measure compared with the conventional 2D approach:
Gn-Co L 2.31 3.04 it is more consistent. The greater variability of the 2D
B-Co L 1.90 2.50
measure reflects the inherent problems of representing
Na-Go R 1.20 1.60
Na-Go L 0.54 1.81 a linear measure in 3D space along a 2D axis. Some
measures markedly underestimate or overestimate the
actual distance. For example, measuring Zyg R-Zyg L
record taking, must remain intact during nonuse, and from the frontal x-ray overestimates the actual distance
must be sturdy enough to handle repetitive use. Any across the skull. The magnitude of enlargement or
movement of the framework while taking pictures and overestimation is related to the distances between the
x-rays can alter the geometric relationship between the focus, the object, and the film. The closer these points
same points on various images. Normally, this should are to the source and the greater the distance between
be a random, nondirectional bias. these points (at a 90° plane), the greater the enlarge-
Most 2D cephalometric measures were not accu- ment from the anatomic truth. The rotation of the head
rate, but some measures were relatively close to the can also alter the measurement between 2 anatomical
physical measure. The cephalometric image of the left sites as seen in the 2D cephalogram. In addition,
side will be magnified 5%-10%, depending on the traditional 2D cephalometric analysis usually does not
distance of the anatomical site from the film plane. correct for magnification error. Most clinicians analyze
When a measurement extends from the midline (eg, Na, a lateral headfilm without adjusting for the magnifica-
Gn) to an anatomical site nearer the film plane (eg, Go tion that can vary from 7% to 12% in most units. We
L, Zyg L, Co L) in the 2D method, the inaccuracy of the used the 2D cephalometric approach as a clinician
measurement is compensated by the magnification, normally would. Even if we adjusted each 2D cepha-
resulting in a value closer to the real measure. When lometric measure by 10%, on a 10-mm difference from
bilateral landmarks are considered, the magnification a true measure defined by the physical caliper, it would
becomes an average of the 2 sides (left, 3%-5%; right, correct the measure only to a 9-mm difference. In
12%-15%; average, 7%-9%). An unexpected finding contrast, the calibration head unit of the Sculptor
was that some measures of 2 midline points (Na-Gn, system corrects for both head rotation and magnifica-
Na-B) showed a large difference from the physical tion on both sides, and does not just correct for an
caliper measure. It was expected that the anatomical average of 2 superimposed images as is done with the
sites in the most lateral positions of the anatomy (eg, 2D cephalometric approach. The 3D Sculptor system
zygomatic arch, gonial angle, condyles) would have the corrects for both bilateral structures. Effective evalua-
American Journal of Orthodontics and Dentofacial Orthopedics Adams et al 405
Volume 126, Number 4

Fig 4. Bland-Altman plot for measurement Na-B. 2D cephalometric measure (green circle) is
markedly different from physical measure of same skull, but 3D Sculptor measure (yellow diamond)
is relatively near true measure. Thickest line (black) represents physical measurement for each of 9
skulls and is set at 0. Mean and 2 SDs for the conventional 2D measurements (red), and mean and
2 SDs for 3D measurement (purple) are shown.

Fig 5. Bland-Altman plot for measurement Gn-Co L. 2D cephalometric measure (green circle) is
relatively near both physical measure of same skull and 3D Sculptor measure (yellow diamond) for
all but 2 skulls. Thickest line (black) represents physical measurement for each of 9 skulls and is set
at 0. The mean and 2 SD for conventional 2D measurements (red), and mean and 2 SDs for 3D
measurement (purple) are shown.
406 Adams et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

Fig 6. Bland-Altman plot for measurement A-Co L. 2D cephalometric measure (green circle) had
large range from physical measure of same skull, but 3D Sculptor measure (yellow diamond) was
relatively near true measure. Thickest line (black) represents physical measurement for each of 9
skulls and is set at 0. Mean and 2 SDs for conventional 2D measurements (red), and mean and 2
SDs for 3D measurement (purple) are shown.

Fig 7. Scatter plot with smoothed lines shows how mean the 76 measurements differ from physical
measurements with 2D cephalometric (red) or 3D Sculptor (blue) approach. Mean of physical
measurements set at 0, and mean of same measurements taken with 2 approaches is compared.
Note that means for Sculptor values are much closer to physical measurements.
American Journal of Orthodontics and Dentofacial Orthopedics Adams et al 407
Volume 126, Number 4

Table VI.76 measures that compared Sculptor 3D Table VI. continued

cephalographic measures to gold standard of physical
measurements Mean
difference SD Minimum Maximum
Mean Measurement (mm) (mm) (mm) (mm)
difference SD Minimum Maximum
Measurement (mm) (mm) (mm) (mm) Zyg R-Co L ⫺1.06 0.33 ⫺1.58 ⫺0.69
Zyg R-Zyg L ⫺1.01 0.32 ⫺1.61 ⫺0.51
S-Go L ⫺1.27 0.34 ⫺1.72 ⫺0.91 Zyg R-ZMX L ⫺1.45 0.55 ⫺2.51 ⫺0.63
S-Co L ⫺0.65 0.73* ⫺1.84 0.30 Zyg R-Go R ⫺0.76 0.46 ⫺1.34 0.28
S-Zyg L ⫺1.19 0.66 ⫺2.75 ⫺0.51 Zyg R-Co R ⫺0.81 0.54 ⫺1.74 ⫺0.18
S-ZMX L ⫺1.30 0.57 ⫺2.09 ⫺0.39 Co R-Go L ⫺0.81 0.49 ⫺1.53 ⫺0.20
S-Go R ⫺0.59 0.88 ⫺1.33 1.47 Co R-Co L ⫺0.99 0.57 ⫺2.30 ⫺0.40
S-Co R ⫺0.85 0.08 ⫺0.91 0.76 Co R-Zyg L ⫺1.75 0.37 ⫺2.47 ⫺1.33
S-Zyg R ⫺0.11 0.42* ⫺0.52 0.80 Co R-ZMX L ⫺2.09 0.61 ⫺2.86 ⫺1.24
S-ZMX R ⫺0.33 0.32* ⫺0.82 0.28 Co R-Go R ⫺0.38 0.33 ⫺0.87 0.06
S-Gn cnm Go R-Go L ⫺0.57 0.47 ⫺1.37 0.14
S-B cnm Go R-Co L ⫺0.93 0.47 ⫺1.95 ⫺0.40
S-A ⫺0.57 1.41* ⫺2.17 1.53 Go R-Zyg L ⫺1.45 0.56 ⫺2.56 ⫺0.80
Go R-ZMX L ⫺1.94 0.52 ⫺3.05 ⫺1.44
S-Na ⫺0.44 0.74* ⫺1.05 0.97
ZMX L-Go L ⫺1.50 0.65 ⫺2.49 ⫺0.72
Na-Go L ⫺1.72 0.41 ⫺2.27 ⫺1.07
ZMX L-Co L ⫺1.39 0.38 ⫺2.20 ⫺0.99
Na-Co L ⫺1.43 0.53 ⫺2.54 ⫺0.90
ZMX L-Zyg L ⫺0.55 0.35 ⫺1.36 ⫺0.22
Na-Zyg L ⫺1.03 0.26 ⫺1.49 ⫺0.78
Zyg L-Go L ⫺1.07 0.63 ⫺2.04 ⫺0.31
Na-ZMX L ⫺0.53 0.26 ⫺0.95 ⫺0.13
Zyg L-Co L ⫺1.01 0.38 ⫺1.54 ⫺0.36
Na-Go R ⫺2.17 0.80 ⫺3.36 0.55 Co L-Go L ⫺0.43 0.33 ⫺0.95 0.08
Na-Co R ⫺2.49 0.49 ⫺3.26 ⫺1.81
Na-Zyg R ⫺1.78 0.48 ⫺2.73 ⫺1.02 Positive mean values indicate differences (biases) from physical caliper
Na-ZMX R ⫺0.89 0.43 ⫺1.89 ⫺0.48 (gold standard) measure overestimate; negative mean values indicate
Na-Gn ⫺1.12 0.35 ⫺1.40 ⫺0.30 differences (biases) from underestimate; cnm, could not be measured.
Na-B ⫺0.81 0.22 ⫺1.08 ⫺0.45 *Coefficient of variation (SD/mean) ⬎1; all were significantly different
Na-A ⫺0.45 0.28 ⫺0.82 ⫺0.06 from 0 (biased) with paired t test (P ⬍ .05) except S-Go R, S-Zyg R,
A-Go L ⫺1.16 0.87 ⫺2.58 ⫺0.14 S-A, S-Na, A-Zyg L, A-ZMX L, B-ZMX R, B-Gn, Gn-ZMX L.
A-Co L ⫺1.15 0.62 ⫺2.00 ⫺0.15
A-Zyg L ⫺0.47 0.62* ⫺1.27 ⫺0.75
A-ZMX L 0.30 1.20* ⫺1.16 2.96 Table VII. Example of 25 measures that compared
A-Go R ⫺2.35 0.80 ⫺3.51 ⫺1.22 Sculptor 3D cephalographic measures to gold
A-Co R ⫺2.24 0.92 ⫺3.99 ⫺1.09 standard of physical measurements ranked by largest
A-Zyg R ⫺1.43 0.45 ⫺2.36 ⫺0.89 to smallest mean differences
A-ZMX R ⫺0.66 0.33 ⫺1.17 ⫺0.01
A-Gn ⫺0.97 0.40 ⫺1.75 ⫺0.43 Mean difference
A-B ⫺0.75 0.32 ⫺1.22 ⫺0.33 Measurement (mm) SD (mm)
B-Go L ⫺0.72 0.37 ⫺1.21 ⫺0.10
B-Co L ⫺0.82 0.29 ⫺1.21 ⫺0.52 Na-Co R 2.49 0.49
B-Zyg L ⫺0.59 0.32 ⫺1.06 ⫺0.19 Na-Go R 2.17 0.80
B-ZMX L ⫺0.66 0.31 ⫺1.13 ⫺0.35 Gn-Go R 2.01 0.36
B-Go R ⫺1.78 0.57 ⫺2.65 ⫺0.99 Gn-Co R 2.01 0.32
Na-Zyg R 1.78 0.48
B-Co R ⫺1.66 0.61 ⫺2.47 ⫺0.54
B-Go R 1.78 0.57
B-Zyg R ⫺0.79 0.65 ⫺1.49 0.33
Na-Go L 1.72 0.41
B-ZMX R ⫺0.31 0.44* ⫺0.91 ⫺0.26
B-Co R 1.66 0.61
B-Gn ⫺0.28 0.32* ⫺0.76 0.14
Na-Co L 1.43 0.53
Gn-Go L ⫺0.65 0.35 ⫺1.16 0.09
Gn-Zyg R 1.20 0.34
Gn-Co L ⫺0.97 0.31 ⫺1.53 ⫺0.51 Na-Gn 1.12 0.35
Gn-Zyg L ⫺0.85 0.48 ⫺1.69 ⫺0.11 Na-Zyg L 1.03 0.26
Gn-ZMX L ⫺0.60 0.86* ⫺2.07 1.17 Zyg L-Zyg R 1.01 0.32
Gn-Go R ⫺2.01 0.36 ⫺2.71 ⫺1.57 Co L-Co R 0.99 0.57
Gn-Co R ⫺2.01 0.32 ⫺2.50 ⫺1.60 A-Gn 0.97 0.40
Gn-Zyg R ⫺1.20 0.34 ⫺1.56 ⫺0.79 Gn-Co L 0.97 0.31
Gn-ZMX R ⫺0.65 0.42 ⫺1.17 ⫺0.03 Gn-Zyg L 0.85 0.48
ZMX R-Go L ⫺0.84 0.23 ⫺1.21 ⫺0.55 B-Co L 0.82 0.29
ZMX R-CoL ⫺0.92 0.26 ⫺1.33 ⫺0.55 Na-B 0.81 0.22
ZMX R-Zyg L ⫺0.67 0.23 ⫺0.97 ⫺0.35 A-B 0.75 0.32
ZMX R-ZMX L ⫺0.57 0.57 ⫺1.06 0.83 B-Go L 0.72 0.37
ZMX R-Go R ⫺1.65 0.55 ⫺2.70 ⫺0.84 Gn-Go L 0.65 0.35
ZMX R-Co R ⫺1.74 0.76 ⫺2.88 ⫺0.71 Go L-Go R 0.57 0.47
ZMX R-Zyg R ⫺0.93 0.36 ⫺1.45 ⫺0.41 Na-A 0.45 0.28
Zyg R-Go L ⫺0.98 0.36 ⫺1.40 ⫺0.34 S-Na 0.44 0.74
408 Adams et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2004

Subset of absolute measures (mm) that compared conventional 2D cephalographic measurements and
Table VIII.
3D Sculptor measurements to gold standard of physical measurements from human skulls (n ⫽ 9)
Mean ⫾ SD Range

Measurement Physical 2D Ceph 3D Sculptor Physical 2D Ceph 3D Sculptor

Na-Go L 110.17 ⫾ 6.35 109.63 ⫾ 7.00 108.45 ⫾ 6.56 103–122 101–123 101–121
Na-Zyg L 73.22 ⫾ 3.73 68.73 ⫾ 3.64 72.19 ⫾ 3.78 70–81 63–75 69–80
Na-Gn 105.08 ⫾ 5.41 114.93 ⫾ 5.69 103.96 ⫾ 5.27 98–114 107–124 97–112
A-B 37.64 ⫾ 2.83 40.75 ⫾ 3.03 36.90 ⫾ 2.75 34–42 37–46 33–41
Gn-Go R 81.04 ⫾ 3.98 70.84 ⫾ 5.74 79.03 ⫾ 3.64 77–89 62–80 75–86
Gn-Co L 113.85 ⫾ 4.79 111.55 ⫾ 5.81 112.89 ⫾ 4.76 106–122 104–122 105–121
GoL-Go R 87.11 ⫾ 7.36 96.12 ⫾ 8.08 86.54 ⫾ 7.19 77–98 84–109 77–98
Zyg L-Zyg R 113.67 ⫾ 5.07 127.29 ⫾ 6.07 112.67 ⫾ 5.01 108–122 121–136 107–121

tion of craniofacial growth will require more accurate
measures in 3 dimensions to be anatomically cor-
rect.47,48
CONCLUSIONS
When using a gold standard of physical measure-
ments from the dry skulls, cephalometric evaluation of
radiographic images taken in the conventional 2D
system often renders both inaccurate and imprecise
measurements. In contrast, the relatively new 3D ceph-
alometric system (Sculptor) provides a much more
precise evaluation of linear measures and only slightly
inaccurate measures that are underestimated by about
1.0 mm. The cephalometric measures from the 3D
Sculptor provide a much more valuable tool in assess-
ing growth and the effects of orthodontic treatment.
The program is used on personal computers (DOS
format) and requires a calibrated headpiece to be worn
by a subject while the radiographs and pictures are
collected. Its relative ease of use, with its powerful
calculation and self-calibrating software, means that it
is a readily accessible program for the clinician.
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