Journal of Orthodontics, Vol.

40, 2013, 225–233

SCIENTIFIC In vitro comparison of contemporary

SECTION
radiographic imaging techniques for
measurement of tooth length:
reliability and radiation dose
Gregor Moze1, Jadbinder Seehra1, Tom Fanshawe2, Jonathan Davies3,
Fraser McDonald4 and Dirk Bister1
1
Department of Orthodontics, Guy’s and St Thomas NHS Foundation Trust, London UK; 2Department of
Primary Care Health Sciences, University of Oxford, Oxford, UK; 3Unit of Dental & Maxillofacial Radiological
Imaging, King’s College London Dental Institute at Guy’s Hospital, London, UK; 4Department of Orthodontics,
King’s College London Dental Institute at Guy’s Hospital, London, UK

Objectives: To measure the reliability of tooth length measurements taken using dental pantomograms (DPT), long cone
periapical radiographs (PR), and cone beam computed tomography (CBCT) and to compare their effective radiation dose.
Subjects and methods: A model containing sixteen anterior teeth was used to simulate a patient undergoing fixed appliance
treatment. PRs were taken at standardized vertical angulations to the occlusal plane (0, 5, 10, 15, and 20u) using conventional
and digital techniques. DPT and CBCT images were also taken. Measurements of radiation dosages were used to estimate a
risk benefit analysis for each of the techniques.
Results: DPT consistently overestimated tooth lengths by 2 mm or more [mean: 2.34 mm; 95% confidence interval (CI):
1.4–3.3 mm]. CBCT consistently underestimated tooth length (mean: 20.89 mm; 95% CI: 20.44 to 21.33 mm). PRs taken at
90u angulation closely resembled the actual tooth length (mean: 20.14 mm; 95% CI: 20.64 to 0.37 mm), but overestimation
occurred with increasing PR film angulation. The radiation dosages ranged widely: DPT plus eight PRs that would be
necessary to assess all teeth and root length of the upper and lower labial segments amounted to 23 mSv. Radiation dose from
CBCT ranged from 17.8 to 60 mSv, depending on equipment and settings.
Key words: Radiation dose, radiographic techniques, tooth length measurement

Received 16 August 2012; accepted 17 February 2013

Introduction (PRs) can be used but are prone to positioning errors

It is generally accepted that orthodontic tooth move-
ment with fixed appliances can result in external root
resorption and a subsequent reduction of overall root
length. The average magnitude of this reduction has
been reported at 1–2 mm.1 Upper and lower incisor
teeth appear to be at greatest risk2 and approximately
1% of orthodontically-treated upper incisors demon-
strate severe root resorption, which has been defined as
a loss of more than one-third of the total root length.3
Evidence of root shortening caused by fixed appliance
treatment is usually detected on radiographs taken near to
the end of treatment. Lateral cephalograms provide
restricted assessment, which is limited to the upper incisors
only.4 Conventional or digital periapical radiographs
relating to the local anatomy and variations in the
positioning of the film and tube. Positioning errors can
lead to both under or overestimation of actual tooth
length. To account for these factors, a variety of mathema-
tical formulas and techniques have been proposed.3,5–7 A
dental pantomogram (DPT) exposes the patient to
significantly less radiation compared to other radiographic
techniques for imaging the entire dentition, such as full
mouth periapical views.8 However, DPTs have their own
limitations, including distortion and superimposition of
anatomical structures, which may lead to misinterpreta-
tion of root length measurements. Correct patient
positioning and proximity of anatomic structure to the
focal trough are prerequisites for good anatomical
representation.9 Contemporary methods such as cone

Address for correspondence: G. Moze, Guy’s and St Thomas NHS

Foundation Trust, Great Maze Pond London, SE1 9RT, UK.
Email: gregor.moze@kcl.ac.uk
# 2013 British Orthodontic Society DOI 10.1179/1465313313Y.0000000049
 226 Moze et al.
Figure 1 Upper and lower study models with 16 previously
extracted teeth set in them. Here the models are positioned in the
DPT
beam computed tomography (CBCT) have been shown to
be a reliable method for measuring and calculating root
length changes during orthodontic treatment.10 The main
disadvantages of CBCT are the higher radiation doses,
limitation of access for many clinicians, and expense.
Radiation doses associated with CBCT machines are
reported to be between 4 and 42 times greater than
panoramic films.11
A widespread comparison of various radiographic
imaging techniques and their ability to detect changes
in tooth length is lacking. The primary aim of this
investigation was to compare the reliability of tooth
length measurements of contemporary radiographic
imaging techniques and align the findings with their
respective radiation dose, to give researchers a guide for
future studies of orthodontic root resorption. Different
resolution settings for the two different tomography
machines were also investigated.
Materials and methods
Ethical approval was obtained from the South East
London Research Ethical Committee (11/H0804/1). A
single set of upper and lower plaster/wax models with 16
previously extracted human teeth was set-up in class
I occlusion to simulate a patient undergoing fixed
appliance treatment. The models were positioned and
stabilized using silicone putty in the respective machines.
Scientific Section JO September 2013
Figure 2 The long cone PA set-up
A reference digital photograph was taken to record each
experimental set-up (Figure 1). PRs (digital and con-
ventional) and DPT/CBCT images were taken in the
clinical teaching classroom and dental radiology depart-
ment at Guy’s and St Thomas’ NHS Foundation Trust,
respectively by trained investigators (GM and JD).
PRs
Two different methods were employed to take the long
cone periapical images of the upper and lower labial
segments:
1. An intraoral film/phosphor plate was positioned
perpendicular to the occlusal plane and the tube
positioned at a defined distance from the film. The
images were taken on three occasions and at five
different angulations of the tube to the film (90, 95,
100, 105 and 110u), the tube was moved vertically to
represent clinical variation in tube positioning.
2. A film holder was used to position the phosphor
plate perpendicular to the X-ray tube at a set
distance (Figure 2). The images were than taken at
five different angulations of the tube to the occlusal
plane (0, 5, 10, 15 and 20u) standardizing the
position of the incisal edge of the teeth by keeping
the edge on the first grove of the film holder. This
set-up simulated the angulation change of the teeth
during orthodontic treatment.
DPT and CBCT
Digital images of the class I set-up model were obtained
using a DPT unit (Planmeca ProMax; Planmeca Oy;
 JO September 2013 Scientific Section Radiographic tooth length assessment and radiation
Helsinki, Finland) and two different CBCT units: (1)
The i-CAT Next Generation (Imaging Sciences Interna-
tional, Hatfield, PA, USA) with four different settings:
0.4 voxel size at 360 and 180u and 0.2 voxel size at 360
and 180u; and (2) The Accuitomo (3D Accuitomo 80; J.
Morita USA, Irvine, CA, USA) at 360 and 180u with a
666 cm field of view.
Measurements
For digital PR and DPT images the tooth length was
measured using computer software (Planmeca Romexis
2.2.5R; Planmeca Oy) displayed on a 19-inch computer
screen to the nearest 0.1 mm under standardized
conditions. For CBCT images, the i-Dixel 2.0 3D
Imaging Software for the Acuitommo and the i-
CATVision Imaging Software for the i-CAT were used.
Conventional PR images were measured using a caliper
and ruler to the nearest 0.5 mm under standardized
conditions. Both crown height and root lengths were
measured. The buccal cemento-enamel junction (CEJ),
defined as the most apical part of the CEJ on the buccal
side of the crown was used to define the border between the
crown and root. Crown lengths were measured from the
most occlusal part of the crown to the most apical part of
the CEJ. The actual tooth root and crown lengths were
also measured, using a caliper and ruler, to the nearest
0.5 mm. The length of the incisors was measured from the
middle of the incisal edge to the apex of the root and for
the canines from the most prominent part of the incisal
edge to the apex of the root. The height of the crown was
measured from the incisal edge to the most apical part of
the CEJ on the buccal surface of the crown. To account for
potential magnification errors, the ratio between the crown
height measured on the images and actual crown height
was calculated and applied to the PR and DPT images.
Reproducibility
Reproducibility was investigated by random selection of
both digital and conventional PRs (20 each). These were
measured twice on two separate occasions, following a 2-
week interval. Coefficient of variance for intra-examiner
reliability was 0.004 for the digital phosphor plates. Method
error for the two techniques was assessed separately and the
Coefficient of variance was 0.015 and 0.017 for digital and
conventional radiography, respectively.
Calculation of radiation dose
The effective radiation dose for each modality used in
this study (periapical films, DPT and the two CBCTs
was obtained from previously published studies
227
(Table 1) and compared to the tooth length assessment
reliability.
Statistical analysis
The measurements obtained by caliper were used as a
gold standard reference. The error for each radiographic
modality was calculated as subtracting the gold stan-
dard from the recorded measurement. Repeated mea-
surements made on the same tooth tended to yield errors
with similar magnitude, so for each modality a linear
mixed effects model was fitted to the error variables,
with the tooth specified as random effect. These models
were used to estimate the average error for each
modality, with 95% confidence interval. A test of
significance of the contrast between each pair of
modalities was used to assess which modalities had
significantly larger errors. Similar mixed effects models
were fitted with measured value as dependent variable
and gold standard as independent variable in order to
compare the regression coefficient (slope) to the value of
1 that would be expected with perfect coincidence of
data.
Results
The measurements of each radiographic modality (a–z,
aa, bb) were plotted against the real tooth length
measurements (Figure 3). For ideal agreement, mea-
surements would coincide with the diagonal line.
Regression coefficients for all modalities are shown in
Figure 4.
Lengths obtained by DPT consistently overestimated
real lengths by 2 mm or more [mean: 2.34 mm; 95%
confidence interval (CI): 1.39 to 3.29 mm] (Figure 4,
modality a).
Both PRs (digital and conventional) performed simi-
larly, also overestimating tooth length. Results obtained
at 90u to the film and occlusal plane resembled the real
tooth length best (mean: 20.14 mm; 95% CI: 20.64 to
0.37 mm) and the result progressively deteriorated as the
tube angulation increased (mean for 110u: 4.62 mm; 95%
CI: 4.32 to 4.92 mm) (Figure 5, modalities c–l). Use of
the film holder showed that 0u to the occlusal plane
underestimated the real tooth length by 0.5 mm (mean:
20.64 mm; 95% CI: 21.36 to 0.07 mm) and this
progressively deteriorated when the film holder angula-
tion to the occlusal plane changed, but to a lesser degree
compared to the PRs without the film holder. Average
overestimation for 20u was 2.17 mm (95% CI: 1.75 to
2.59 mm) (Figure 5, modalities s–w).
The ‘calculated tooth length’ was established using the
magnification factor from the difference of the real
 228 Moze et al. Scientific Section JO September 2013

Figure 3 Tooth length measurements on X-ray images (y axis), real tooth length (x axis): a: DPT; c: PR analog 90u; g: PR analog 110u;
h: PR digital 90u; l: PR digital 110u; q: Aucittomo 360u; s: PR digital with film holder 0u; w: PA digital with film holder, 20m; z: PA
digital (calculated tooth length) 10m

crown length to the crown length of the radiograph.
This magnification factor was then used to calculate the
tooth length. Values for the ‘calculated tooth lengths’
performed similarly to the directly measured from the
radiographs (both for DPT and PR), but with more
variability, as shown by the confidence intervals
(Figure 5, modalities b for the DPT and x–bb for PR).
All CBCT results consistently underestimated tooth
length by 0.5–1 mm, with similar measurement errors
(mean: 20.89 mm; 95% CI: 21.33 to 0.44 mm) (Figure 5,
modalities m–r).
The overall predictive performances of modality pairs
were also compared (Figure 6) and no major difference
between PR (both conventional and digital) taken at 90
 JO September 2013 Scientific Section Radiographic tooth length assessment and radiation 229

Figure 4 Regression coefficients for all modalities: a: DPT; b: DPT X; c: PR, 90u; d: PR, 95u; e: PR, 100u; f: PR, 105u; g: PR, 110u; h:
PR digital, 90u; I: PR digital, 95u; j: PR digital, 100u; k: PR digital, 105u; l: PR digital, 110u; m: i-CAT, 0.4; n: i-CAT, 0.2; o: i-CAT, 0.4,
180u; p: i-CAT, 0.2, 180u; q: Aucittomo, 360u; r: Aucittomo, 180u; s: PR digital with film holder, 0u; t: PR digital with film holder, 5u; u:
PR digital with film holder, 10u; v: PR digital with film holder, 15u; w: PR digital with film holder, 20u; x: PR digital (calculated tooth
length) 0u; y: PR digital (calculated tooth length) 5u; z: PR digital (calculated tooth length) 10u; aa: PR digital (calculated tooth length) 15u;
bb: PR digital (calculated tooth length) 20u

and 95u as well as all six of the CBCT modalities tested of a single PR image was less than 1.5 mSv. The
were found. radiation dose for a high definition i-CAT CBCT can
The measured effective radiation doses for the be up to 60 mSv. The effective dose from the DPT was
modalities tested are presented in Table 1 and the dose 11.3 mSv.

Table 1 Radiation dosage for the radiographic modalities/machines used in the present study.

X-ray modality Ref. Effective radiation dose

Intra oral periapical 11 ,1.5 mSv (12 mSv for upperzlower labial teeth)
DPT (15630 cm) 26 11.3 mSv
DPT collimated 26 6 mSv
Lateral cephalogram (conventional) 30 5 mSv
Lateral cephalogram (digital) 31 2.2–5.6 mSv
CBCT 32 11–674 mSv
i-CAT NG 0.4 vox 360u 29 32 mSv
i-CAT NG 0.2 vox 360u 29 60 mSv
i-CAT NG 0.4 vox 180u 29 17.8 mSv
i-CAT NG 0.2 vox 180u 29 34 mSv
Accuitomo FPD 6 cm 360u 27 43.27 mSv
Accuitomo FPD 6 cm 180u 29 32.6 mSv
 230 Moze et al. Scientific Section JO September 2013

Figure 5 A comparative summary of the performance of each modality. The difference between measured value and the gold standard is
represented by a mean and 95% confidence interval (shown by the black dot and attached line). Modalities are labeled on the x axis. The
dotted horizontal lines show the zero mean difference (which would be expected if measurements were perfect) and differences of ¡0.5 mm,
the minimum clinically important difference are also shown: a: DPT; b: DPT X; c: PR, 90u; d: PR, 95u; e: PR, 100u; f: PR, 105u; g: PR,
110u; h: PR digital, 90u; I: PR digital, 95u; j: PR digital, 100u; k: PR digital, 105u; l: PR digital, 110u; m: i-CAT, 0.4; n: i-CAT, 0.2; o: i-
CAT, 0.4, 180u; p: i-CAT, 0.2, 180u; q: Aucittomo, 360u; r: Aucittomo, 180u; s: PR digital with film holder, 0u; t: PR digital with film
holder, 5u; u: PR digital with film holder, 10u; v: PR digital with film holder, 15u; w: PR digital with film holder, 20u; x: PR digital
(calculated tooth length) 0u; y: PR digital (calculated tooth length) 5u; z: PR digital (calculated tooth length) 10u; aa: PR digital (calculated
tooth length) 15u; bb: PR digital (calculated tooth length) 20u

Discussion orthodontically induced root resorption is described as

In this investigation the reliability of modern radio-
graphic imaging techniques (PR, DPT, and CBCT) for
tooth length measurements were evaluated and com-
pared with their effective radiation dose. We found that
a PR taken at exactly 90u to the tooth gave the closest
estimation of real tooth length, but accuracy declined
when tube angulation was changed. DPTs were the least
reliable technique, with more than 2 mm of tooth length
overestimation compared to the real tooth length. Both
CBCT machines used in this investigation, Accuitomo
and i-CAT, performed similarly, both consistently
underestimating the real tooth length by 0.5–1 mm. i-
CAT CBCTs exposed the patient to less radiation of the
two. Change of resolution did not have an impact on the
precision of the measurements but increased radiation
dosage. If effectiveness in radiographic assessment of
level of accuracy of the technique against amount of
radiation dose, than the most effective method of
investigation is the CBCT, with the lowest radiation
dose and highest reliability.
Root resorption is a known risk of orthodontic
treatment and its severity is assessed radiographically.
Long cone PRs were long thought to provide the most
reliable method to assess root resorption, although this
technique was known to be prone to several sources of
error, such as variations of tube and film positioning,12
magnification landmark identification errors7 and changes
in tooth position.7 The use of DPTs for assessment of root
length is controversial but they remain popular in scientific
investigations assessing root resorption.13 High levels of
accuracy and reproducibility with the CBCT have been
previously reported but are associated with higher
radiation exposure to patient.10 Our investigation tried
 JO September 2013 Scientific Section Radiographic tooth length assessment and radiation
Figure 6 Direct comparison of the 18 modalities. Each coloured
square indicates a P value for the test, for each pair of modalities
(labeled in the same row/column). Yellow squares indicate pairs of
modalities that are significantly different from each other, while red
squares indicates pairs of modalities that are not: a: DPT; b: DPT
X; c: PR, 90u, d: PR, 95u, e: PR, 100u, f: PR, 105u, g: PR, 110 , h:
PR digital, 90u, I: PR digital, 95u, j: PR digital, 100u, k: PR digital,
105u, l: PR digital, 110u, m: i-CAT, 0.4, n: i-CAT, 0.2, o: i-CAT,
0.4, 180u, p: i-CAT, 0.2, 180, u, q: Aucittomo, 360u, r: Aucittomo,
180u
to ascertain the best modality for measuring root length
allowing future studies assessing root resorption, to use the
most accurate method with the lowest possible radiation
burden for patients.
Different methods have been used previously to
account for positioning and magnification error of PRs.
The present results demonstrate that at exactly 90u the
periapical technique resulted in the most accurate root
and tooth length measurements. However, the results
became less accurate as the angulation changed and other
authors have tried to counteract this distortion. The
occlusal registration found no change in the distance
between the lower border of the bracket to the apex on
images taken with an occlusal registration fixed to the
positioning device and changing the angulation of the
tube.14 The individual jig technique was found to be
reliable, but additional radiographs7 are necessary,
increasing radiation exposure. Calculation of ‘crown
ratio’ mathematically has been also used to address
magnification errors. These are based on the difference
between measured crown heights taken of same tooth on
two separate occasions.2,6 This assumes that the crown
231
height of the tooth does not change, but this can happen
in attrition or trauma. In our study, the use of this ratio
did not counteract the overestimation of the tooth length
when the tube/film angulation to the occlusal plane
changed and the calculated tooth length showed great
variation as reflected by the wide confidence intervals.
This was due to a landmark identification error, the CEJ
was difficult to identify reliably on the radiographs.
The accuracy of DPT images for the assessment of
root resorption is more controversial. Comparison of
the accuracy of PR, DPT, linear tomographic and CT
images, using a human edentulous mandible with
metallic implants, revealed that the most reliable
method for assessing root length was the long cone
periapical imaging technique.15 DPTs overestimated real
measurements by more than 2 mm (1.4–3.3 mm). This
variation did not improve when the position of the
patient was changed in the set-up and results were
similar for upper and lower front teeth. The amount of
distortion is variable16 but a 20% overestimation of the
amount of root resorption using this technique has been
reported.17 Variation of patient positioning and distor-
tion of images of the labial segment make the DPT less
reliable for assessing root resorption.17,18 Good quality
radiographs are a prerequisite to detect teeth with
predisposing risk factors for root resorption, such as
spindle shaped and short roots. The initial prescription
of a DPT and additional PRs where the morphology of
the roots cannot be clearly visualized has been
proposed.17
In this investigation, CBCT consistently underesti-
mated tooth length by 0.5–1 mm, which confirms the
findings of previous authors.19,20 CBCT measurements
for inter-occulsal and arch parameters have both been
reported to be underestimated compared to actual
values.21 Comparison of linear CBCT measurements
and anatomical landmarks and demonstrated a 1.13%
underestimation, with 90% of mean differences being
less than 2 mm.22
In this study we also compared the radiation dosages
of different imaging techniques with their respective
accuracy in assessing tooth length. A number of studies
have measured the effective radiation doses for different
radiographic imaging techniques in dentistry. Radiation
doses for CBCT have been reported to range between 11
and 674 mSv, depending on the type of CBCT machine
and the settings used.23–25 Interestingly, the radiation
dosage for eight PRs that would be necessary to assess
the upper and lower labial segment would be approxi-
mately 12 mSv. Taking into account the 11.3 mSv
required for a digital DPT26 the overall effective
radiation dose would increase to 23.3 mSv. The effective
dose for an i-CAT scan was only 17.8 mSv using the
 232 Moze et al. Scientific Section
Table 2 Radiation dosages for the radiographic modalities/machines
used to assess root resorption.
Radiographic modalities Effective radiation dose
DPTz8 PA 23 mSv
DPTzLC 13.5 mSv
DPTzLCz8 PA 25.2 mSv
Full mouth periapicals (16X) 32 mSv
i-CAT NG 0.4 vox 180u 17.8 mSv
Accuitomo FPD 6 cm 180u 32.6 mSv
PA, periapicals; LC, lateral cephalogram.
lowest resolution (i-CAT NG at 180u and 0.4 voxel size),
which results in less radiation exposure compared to
conventional radiographs (Table 2). Enlarging the angle
to 360u on the i-CAT and/or increasing the resolution of
the image leads to a concomitant increase of radiation
dosage but does not improve precision of the measure-
ments. The Accuitomo has a smaller field of view
(666 cm compared to 17623 cm for the i-Cat) but its
effective dose is higher than that of the i-CAT for all
settings.27
Our investigation used existing data for radiation
dosage and combined this with a model to assess
accuracy of tooth length measurements of three
different radiographic modalities. General conclusions
can be drawn from the results obtained from the PR
radiographs for radiation dosage and tooth length
measurements, but not for the DPT and CBCT. The
results pertaining to the latter two modalities are specific
to the machines used in this investigation. However, we
have demonstrated that a low-resolution i-CAT CBCT
has a similar effective radiation dose compared to that
of a DPT and the eight PRs necessary to accurately
assess upper and lower incisor root lengths. On this
basis a i-CAT CBCT as a baseline investigation for
patients known to have an increased risk of root
resorption could be recommended.
Routine orthodontic radiographic assessment often
involves a combination of a lateral cephalogram and a
DPT. The effective radiation dose of those two radio-
graphs is comparable to a low dose CBCT but may also
exceed it. The lowest radiation dose from the i-CAT was
17.8 mSv and the lowest radiation dose from a DPT and
cephalometric view is 13.5 mSv. However, the latter
depends on the equipment used and could increase to
19.9 mSv. A CBCT from the i-CAT does not always
allow for reconstruction of a full cephalometric view,
particularly if patients have a large head.28 Hence,
recommendation of i-CAT CBCT for patients who need
cephalometric assessment as well as a DPT cannot be
made routinely.
JO September 2013
Conclusions
N Long cone PR images taken at exactly 90u to the
tooth gave the closest estimation of real tooth length,
but with a linear decline in accuracy when the tube
angulation was changed, regardless of adjustments.
N A DPT was shown to be the least reliable technique
with more than 2 mm of tooth length overestimation
compared to real tooth length.
N The two different CBCT machines used in this study,
Accuitomo and i-CAT, both consistently underesti-
mated real tooth lengths by 0.5–1 mm, but the i-CAT
exposed the patient to less radiation. Change of
resolution did not have an impact on the precision of
the measurements for either machine.
N A low-resolution i-CAT CBCT has a similar effective
radiation dose when compared to a combination of
DPT and 8 PRs that are necessary to accurately assess
the upper and lower labial segment root lengths.
Acknowledgements
The authors are grateful Mr Nikolas Maschas and Mr
Andrew Noon for construction of the study models.
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