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Available online at

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www.sciencedirect.com

Original Article

Evaluation of an online website-based platform for cephalometric

analysis
H. Alqahtani
Orthodontic department, dental school, King Abdulaziz University, Jeddah, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Article history: Background: The purpose of our study was to assess the reproducibility of linear and angular
Received 8 February 2019 measurements of cephalogram tracings made with an online website-based platform CephX1 vs.
Accepted 24 April 2019 tracings made using the FACAD1 computer software.
Methods: Thirty cephalometric radiographs were selected randomly to be used in this study. A total of
Keywords: 16 landmarks and 16 measurements (8 linear and 8 angular) were defined. We used paired t-test to
Cephalometry compare mean differences between both methods. Concordance Correlation Coefficient (CCC) and
FACAD
Bland-Altman analyses were used to evaluate reproducibility of measurements. The level of statistical
CephX
Reproducibility
significance was set at P < 0.05.
Results: We did not find a statistically significant mean difference between the two methods except for
two angular measurements SNA, FMA and one linear measurement Pg to NB. The highest magnitude of
the difference between sample means was 1.98 and 0.78 mm for the angular and linear measurements
respectively. The SE value was less than 0.18 for the angular measurements and less than 0.3 mm for the
linear measurements. All parameters except POG to NB showed moderate to almost perfect agreement
(>0.90).
Conclusion: The measurements obtained by both softwares FACAD1 and CephX1 are reproducible.
Although significant differences were detected for some measurements, all differences were not
clinically significant.
C 2019 Elsevier Masson SAS. All rights reserved.

1. Introduction
Broadbent has introduced the cephalometric radiography
which has been utilized in the prediction of craniofacial growth,
orthodontic diagnosis, treatment planning, treatment progress,
and evaluation of results [1]. Acetate overlays have been used for
many years to trace lateral cephalograms manually by identifying
landmarks and measuring angular and linear values with a ruler
and protractor. This method is time-consuming, susceptible to
errors, and risks misreading values. Manual tracing is prone to
error as a result of landmark identification and radiographic film
magnification [2,3]. This has largely been overcome in the past few
years through advances in computer science and the digitalization
of cephalometric analysis [4]. Thus, manual tracing has been
slowly replaced with the digital tracing methods.
Digital cephalometric tracing requires a digital lateral cephalo-
gram image that can be displayed on a computer. This image can be
obtained directly by using a charged coupled device sensor (direct
E-mail address: hsalqahtani@kau.edu.sa
digitization) while avoiding the use of conventional x-ray film and
darkroom exposures. The image can also be acquired by converting
conventional x-ray film to a digital format, using a scanner or video
camera [5]. It is then transferred to a software program that
enables users to recognize and digitize different anatomical points
and execute cephalometric analysis [6,7].
Computer-assisted cephalometric analysis has many benefits; it
is easy to process, does not require hard copies [8], performs several
analyses at once and is convenient during treatment prediction [9],
easily modifies the contrast and size of the image, provides better
archiving and accessibility to digital images [10,11], produces faster
analysis, and reduces radiation exposure [8].
Many computer programs have been developed for cephalo-
metric analysis, such as Dolphin1 Imaging, Dentofacial Planner1,
Quick Ceph1, and FACAD1. Many studies have assessed the
accuracy and reliability of manual cephalometric analysis versus
digital cephalometric analysis and found that both methods were
comparable [12–14].
Various cephalometric analysis programs have been designed
to run on a personal computer or local network. A number of
factors affect the choice of software, such as complicated

https://doi.org/10.1016/j.jormas.2019.04.017
2468-7855/ C 2019 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Alqahtani H. Evaluation of an online website-based platform for cephalometric analysis. J Stomatol
Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.04.017
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2 H. Alqahtani / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx

installation procedures, expensive subscription and update fees,

the need for multiple tutorials, and significant practice to master
the program. Also, these programs require digital storage to
maintain patients’ records and data, which becomes a problem
over time, especially in expanding or large orthodontic offices.
CephX1 (cephX, Inc., Las Vegas, Nevada) is a web-based
platform and cloud system that can be utilized for cephalometric
analyses, image archiving, and patient record management. It uses
artificial intelligence-based algorithms (AlgoCeph technology) to
perform cephalometric tracing. This technology provides ortho-
dontists with cephalometric analysis within a few seconds, which
can save time. This system can work with any device or operating
system.
The reproducibility and accuracy of cephalometric analysis that
uses this platform have not been evaluated or documented in the
literature. This study aimed to compare the reproducibility of
cephalogram tracings done with the web-based platform CephX1
versus tracings done with the FACAD1 computer software, which
has been proven comparable with manual cephalometric tracings
[14–16].

2. Materials and methods

Thirty cephalometric radiographs were selected randomly from

Fig. 1. The cephalometric landmarks used in this study: S, Sella; N, nasion; Or,
records of patients who visited our orthodontic department over orbitale; Po, porion; Ar, articulare; ANS, anterior nasal spine; A, point A; B, point B;
the past 6 years. This study was conducted according to the Pog, pogonion; Me, menton; Go, gonion; Gn, Gnathion; Is, Incision superior incisal:
guidelines of our school’s Research Ethics Committee. Selection of the midpoint of the incisal edge of the most prominent maxillary central incisor;
U1A, upper incisor root apex; Ii, Incision inferior: the midpoint of the incisal edge of
the cephalometric radiographs was based on radiographs of good
the most prominent mandibular central incisor; L1A, lower incisor root apex.
quality that showed no artifacts and were performed on the same
machine. Radiographs that showed major asymmetry, lack of
resolution, or craniofacial deformity were excluded. All X-rays
were obtained digitally by trained radiographic technicians in a
standardized manner, using a Kodak 8000C machine, France with a Table 1
Cephalometric measurements used in this study.
sensor dimension of 1360  1840. The Kodak 8000C has a 40-mm
ruler within the digital cassette. The image of this ruler was Definition
reflected in all cephalometric radiographs for calibration purposes. Measurements in degrees
The digital images were stored in a computer database with Kodak SNA Angle determined by points S, N, and A
Dental Imaging Software, version 6.12.32 (Carestream Health Inc., SNB Angle determined by points S, N, and B
Rochester, New York, USA). A total of 16 landmarks (Fig. 1) and ANB Angle determined by points A, N and B
FMA The angle formed between the mandibular
16 measurements (8 linear and 8 angular) were selected to be used
plane and Frankfort Horizontal Plane
in this study. (Table 1). FMIA The angle formed between long axis of lower
We created an account on the CephX1 website to use for our central incisor and the Frankfort Horizontal
study. All 30 cephalograms were uploaded and within seconds, all Plane
IMPA The angle formed between long axis of lower
radiographs were traced by the website. Some landmarks were
central incisor and the mandibular plane
adjusted by the author (HA). All images were calibrated by I/ to NA Angle formed between axis of upper incisor to
digitizing two points on the ruler. Full set of cephalometric NA plane
analyses was ready to view. All measurement values were /I to NB Angle formed between axis of lower incisor to
extracted from the CephX1 database for each image. NB plane

To maintain high reliability in detecting anatomical landmarks, Measurements in mm

all images, with their overlay tracings and detected landmarks, A to Na Perp Distance from point A to line perpendicular to
were downloaded from the CephX1 website and stored as JPEG FH plane from point N
Pog to Na Perp Distance from point Pog to line perpendicular to
images (Fig. 2). Next, the images were imported into the FACAD1 FH plane from point N
(Ilexis AB, Linköping, Sweden) software. Calibration was per- Go-Gn Distance between point Go and Gn
formed on the ruler; the same landmarks were detected in the S-Go Distance between point S and Go
identical position, as determined by CephX1. Ar-Go Distance between point Ar and Go
ANS to Me Distance between point ANS and Me
Data entry was carried out manually. Statistical analysis was
Pog to NB Distance between point Pog and NB
conducted using STATA version 13.0 (StataCorp, College Station, N-S Distance between point N and S
Texas, USA). The mean and standard deviation (SD) of all
measurements were calculated for both methods. Also, the mean
(SD) and standard error (SE) of the difference between the two
methods were analyzed. The comparison of the measures was
tested by paired t-test. interval of the difference were also calculated as well as the Bland
Furthermore, the reproducibility of the measurements was and Altman limit of agreement. The comparison of the mean
determined by the concordance correlation coefficient (CCC) and difference between both programs was calculated with the
standard error. The mean, standard deviation, and 95% confidence Bradley-Blackwood test. The significance level was set at P < 0.05.

Please cite this article in press as: Alqahtani H. Evaluation of an online website-based platform for cephalometric analysis. J Stomatol
Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.04.017
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Table 3
The outcome measurements presented by concordance correlation coefficient and
Bland and Altman limit of agreement.

Concordance correlation Bland and

coefficient Altman
agreement

Measurement Rhoa SE 95% CI 95% Limits

Upper Lower Upper Lower

Measurements in degrees
SNA 0.996 0.002 0.992 0.999 0.444 0.697
SNB 0.999 0 0.998 1 0.348 0.446
ANB 0.997 0.001 0.994 0.999 0.346 0.502
FMA 0.938 0.016 0.906 0.969 1.063 2.868
FMIA 0.997 0.001 0.995 0.999 1.124 1.271
IMPA 0.997 0.001 0.994 0.999 1.254 1.13
I/ to NA 0.997 0.001 0.995 0.999 1.182 1.257
I/ to NB 0.996 0.001 0.993 0.999 1.141 1.013

Measurements in mm
A to Na Perp 0.995 0.002 0.991 0.999 0.512 0.664
Pog to Na Perp 0.999 0 0.998 1 0.849 0.74
Go-Gn 0.926 0.026 0.875 0.976 3.338 3.654
S-Go 0.91 0.032 0.848 0.973 3.057 3.438
Ar-Go 0.952 0.018 0.917 0.987 1.79 1.956
ANS to Me 0.964 0.013 0.938 0.989 2.686 3.195
POG to NB 0.739 0.063 0.615 0.862 2.719 1.159
N-S 0.912 0.031 0.852 0.972 2.837 3.186
a
<0.9 Poor, 0.9–0.95 Moderate, 0.96–0.99 Substantial, >0.99 Almost perfect.
Fig. 2. An example of a traced ceph downloaded from CephX1 website.

3. Results agreement between the two methods. Also, Bland-Altman analyses

The comparison between the measurements of CephX1 and
FACAD1 is shown in Table 2. A paired t-test showed that most
measurements did not differ significantly between the two
methods. The only significant differences were detected in two
angular measurements (SNA and FMA) and one linear measure-
ment (Pg to NB). The highest magnitude of the difference between
sample means was 1.90 and 0.78 mm for the angular and linear
measurements, respectively. The SE value was less than 0.10 for
the angular measurements and less than 0.3 mm for the linear
measurements.
Table 3 shows how the CCC was used to assess the level of
agreement and reproducibility between the two methods. POG to
NB was the only measurement that showed poor agreement. All
other measurements showed moderate to almost perfect
and plots indicated a high level of agreement (see the supplemen-
tal document).
4. Discussion
Many studies have investigated the accuracy and reproducibil-
ity of cephalometric measurements obtained from manual and
digital cephalometric analyses (Table 4). Erkan et al. [13] compared
four tracing programs (Dolphin1, Nemoceph1, Vistadent1, and
Quick Ceph1) with manual cephalometric tracing. Erkan and
colleagues used scanned lateral cephalograms at 300 dpi and were
digitized on-screen. They found no statistically significant
differences between digital and manual methods. Moreover, only
a small number of differences was noticed in the angles and length
between methods. The greatest difference was detected for

Table 2
Mean differences, SD, SE and paired t-test for comparison between FACAD and CephX.

Measurement FACAD CEPH X Difference P-valuea

Mean SD Mean SD Mean SD SE

Measurements in degrees
SNA 82.6 3.4 82.4 3.3 0.2 0.3 0.05 0.02
SNB 78.6 4.4 78.5 4.4 0.1 0.2 0.04 0.1
ANB 3.9 2.8 3.9 2.9 0 0.2 0.04 0.058
FMA 29.5 5.7 27.6 5.5 1.9 0.5 0.08 <0.0001
FMIA 60.3 7.8 60.2 7.6 0.1 0.6 0.11 0.5
IMPA 90.2 7.5 90.2 7.5 0 0.6 0.11 0.5
I/ to NA 29.9 8.5 29.9 8.4 0 0.6 0.11 0.7
/I to NB 28.5 6.3 28.6 6.1 0.1 0.5 0.1 0.5
Measurements in mm
A to Na Perp 2.6 3.1 2.5 3 0.1 0.3 0.05 0.1
Pog to Na Perp 2.3 8.2 2.3 8.1 0 0.4 0.07 0.4
Go-Gn 70.8 4.4 70.7 4.9 0.1 1.8 0.32 0.6
S-Go 64.4 3.8 64.2 4.1 0.2 1.7 0.3 0.5
Ar-Go 36.3 3.1 36.2 3.1 0.1 0.96 0.17 0.6
ANS to Me 61.3 5.9 61 5.4 0.3 1.5 0.27 0.3
POG to NB 0.01 1.9 0.79 1.3 0.78 0.99 0.18 0.0002
N-S 63.7 3.5 63.6 3.9 0.1 1.5 0.28 0.5
a
Paired t-test.

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Table 4
The published studies on reproducibility of measurements from different tracing methods.

Author Year Sample Tracing methods Parameters Statistical tests Findings

size
b
Naoumova and Lindman [14] 2009 30 FACAD1 vs. manual SNA, SNB, ANB, SNPg, Cm-Sn-Ls Paired t-test
tracing Nasolabial angle, G-Sn-Pg’ Facial
convexity, Ii-Li, B-Si, P to Pg’, Si to Li –
Pg’, Sn – A
a
Erkan et al. [12,13] 2012 30 Dolphin, Vistadent, SN–palatal plane (PP), saddle angle, Multivariate analysis of
Nemoceph, Quick SNA, lower lip–E plane distance, SNB, variance (MANOVA), Box’s and
Ceph VS. manual facial depth angle, convexity angle, Levene’s tests, and pairwise
tracing. ANB, U1–L1 angle, maxillary depth comparison
angle, L–NB distance, N–ANS distance,
ANS–Me distance, N–Me distance, U1–
PP
b
AlBarakati et al. [12] 2012 30 Dolphin vs. manual SNA, SNB, ANB, angle of convexity, SN– Paired t-test
tracing MP, SN–PP, PP–MP, gonial angle, U1–
SN, U1–MP, NS, Co–ANS, ANS–PNS, Co-
Gn, Go–Gn, ANS–Me
b
Farooq et al. [15] 2016 50 FACAD1 vs. manual 30 parameters from Tweeds, Steiner, Independent t-test
tracing McNamara, Wits and Jarabaks
b
Hardik et al. [16] 2016 60 SNA, SNB, ANB, N Pog -FH, OL/NSL, U1 Paired t-test
to NA, L1 to NB, U1/L1, OP -FH, Go-Gn -
SN, N-ANS, ANS-Gn, Ar-Go, Go-Pog,
PNS-ANS, Pog-Pog’, Me-Me’
b
Aksakallı et al. [19] 2017 20 CephNinja and SNA, SNB, ANB, Max Mand Plane angle, Bland-Altman analysis
SmartCeph Pro vs. U1/Max Plane, L1/Mand Plane, U1-L1,
Dolphin Lower Lip/E Line, Upper Lip/E Line, SN,
Wits, FMA, Saddle Angle between N, S,
Ar, Articular: Angle between S, Ar, and
Go, Gonial: Angle between Ar, Go, and
Gn points, Sum of angles: Total amount
of Saddle, Articular, and Gonial angles
b
Sayar and Kilinc [20] 2017 55 CephNinja app vs. SNA, SNB, ANB, U1–NA, L1–NB, Go-GN/ Paired t-test
manual tracing SN, Occlusal plane to SN, U1/L1, U1–NA
distance, L1–NB distance, upper lip to
Steiner’s S line, lower lip to Steiner’s S
line
a
No statistically significant difference.
b
Statistically significant difference in one variable or more.

Vistadent and the least for Dolphin1. Erkin and colleagues
concluded that the measurements obtained with these programs
were reliable. AlBarakati et al. [12] compared the angular and
linear measurements of manual tracing versus tracings made with
Dolphin1 Imaging Software. Statistically significant differences
were found between the two techniques in many linear and
angular measurements except for the anterior cranial base, ANB
angle, lower anterior facial height, and angle of convexity. Most of
these differences were not clinically significant.
Rapid advances in computer technology and software pro-
gramming have led to a significant shift in using newer technology
for cephalometric analysis, including applications loaded onto
smartphones or tablet PCs. Apps are defined as specialized
software downloaded to smartphones or tablets [17]. CephNinja1,
SmartCeph Pro1, SimplyCeph1, and SmileCeph International1 are
examples of apps compatible with an iPad that can be used for
cephalometric analysis[18]. Aksakallı et al. [19] contrasted
measurements obtained with the iPad apps SmartCeph Pro1
and CephNinja1 with measurements acquired using Dolphin1
Imaging computer software. Of the 16 measurements obtained
from each program, seven measurements for CephNinja1 and six
measurements for SmartCeph1 Pro were comparable with
Dolphin1 software. The two apps provided better results for
angular measurements than linear measurements. Aksakallı and
colleagues concluded that orthodontic apps are not as efficient as
Dolphin1 software, and need more improvement to be reliable for
most measurements. Sayar and Kilinc[20] compared the results of
conventional manual cephalometric tracing with the results from
the CephNinja1 app. Sayar and Kilinc found statistically significant
differences in 8 of 12 measurements between the two methods.
Sayar and Kilinc concluded that these differences were not
clinically significant, and tracing was faster with the CephNinja1
app than with the manual method.
We compared CephX1 with FACAD1, which we used as our
gold standard software because previous studies have proved the
accuracy of cephalometric analysis using FACAD1. Naoumova and
Lindman [14] compared cephalometric measurements made with
FACAD1 software to equivalent manual tracing measurements.
The differences between measurements with both methods were
1 unit (mm or degree) for all variables. Statistically significant
differences were found between the methods for Gn (gnathion), Li
(labrale inferius), Si (mentolabial sulcus), and Ii – Li (soft tissue
thickness) but were not clinically significant. The results of both
tracing techniques were similar, indicating that FACAD1 is reliable
and can be routinely used. Farooq et al. [15] found a high
correlation between the measurements using FACAD1 and the
conventional method. Both methods showed consistent measu-
rements, except for 1-NA, Y-axis, and interincisal angle measu-
rements, which were higher in manual tracing, and the facial axis
angle, which was higher in digital tracing. Hardik et al. [16]
compared both linear and angular measurements using hand
tracing of digital cephalometric radiographs and FACAD1 software.
Hardik and colleagues found statistically significant differences in
the occlusal plane to SN angle, cant of occlusal plane, interincisal
angle, Go – Gn to SN, and facial angle. Hardik and colleagues
concluded that measurements made with FACAD1 software and
the conventional method are valid, reliable, and highly correlated.
It is very important in orthodontic treatment planning to have
an accurate cephalometric analysis that allows practitioners to
diagnose cases accurately, assess different treatment modalities,

Please cite this article in press as: Alqahtani H. Evaluation of an online website-based platform for cephalometric analysis. J Stomatol
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evaluate treatment progress, and predict treatment outcomes. In
recent years, computers have been widely used in cephalometry.
Therefore, we were interested in comparing tracings made with
CephX1 vs. FACAD1 in terms of reproducibility, which is defined as
an agreement between two measurements of two methods [21].
One of the major sources of error in cephalometric tracing is
landmark identification. In general, interexaminer error is greater
than intraexaminer error [11]. To make landmark identification
highly reliable and to exclude it as a confounding factor, we
downloaded all images with their overlay tracings, detected
landmarks from the CephX1 website, and stored them as JPEG
images in a computer database (Fig. 2). We then imported the
images into FACAD1, where we placed all landmarks in the same
precise locations detected by CephX1.
All lateral cephalograms in this study were obtained directly in a
digital format. This step eliminated the demand for scanning
conventional radiographic films, which is time-consuming, prone to
poor quality, and may cause magnification errors [10]. Cephalomet-
ric analysis software can make landmark identification more
precise because once the images are detected on-screen, measu-
rements and data processing occur automatically. In contrast, the
conventional method requires rulers and protractors to accomplish
the same job [22]. The digital technique is prone to some errors. This
can be caused by analog cephalometric radiographs with improper
quality that displays poorly on a computer screen and results in
lower quality, unknown formats, unknown gray shades, and
unknown parameters [23–25]. The number of pixels (gray scale)
is affected by the compression technique often found in digital
images. We used the JPEG format with standard compression
settings, which do not affect the image diagnostic quality [26,27].
CephX1 uses AlgoCeph technology, which enables orthodon-
tists to obtain accurate cephalometric tracing and analysis within
seconds. AlgoCeph technology utilizes artificial intelligence and
machine learning technology to automate cephalometric tracing
and analysis. This technology uses a specific algorithm to detect
anatomical landmarks, perform calibrations, and check for
accuracy. This is the first study conducted to examine the
reproducibility of measurements between the CephX1 platform
and FACAD1.
Our results did not find statistically significant differences
between the two methods for most of the measurements, except
for two angular measurements (SNA and FMA) and one linear
measurement (Pg to NB). In the conventional method, measure-
ment differences of less than 2 units are considered within one SD
of normal values [7,28]. Therefore, any measurement variance of
more than 2 units (degree or mm) is considered a clinically
significant difference. In our study, no measurements showed a
difference of more than 2 units. FMA showed the largest
measurement difference, 1.9 mm.
Previous studies used the paired t-test to evaluate the
reproducibility of measurements obtained by different tracing
methods [12,14,16,20]. In addition to the paired t-test, we used
CCC, which is considered as the statistical method of choice to
assess the agreement between paired values [29]. Also, we utilized
Bland-Altman analyses and plots to visualize the error between
methods across a range of measurements. Almost all measure-
ments showed moderate to almost perfect agreement between
both methods. Therefore, this study confirms that both programs
can perform cephalometric analysis with comparable accuracy and
reproducibility.
5. Conclusion
The cephalometric measurements obtained from both FACAD1
and CephX1 are highly reproducible. The advantages of an online
Please cite this article in press as: Alqahtani H. Evaluation of an online website-based platform for cephalometric analysis. J Stomatol
Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.04.017
5
website-based platform for cephalometric analysis such as cloud-
based storage, online archiving, quick analysis, no need for specific
installation or software, and compatibility with any operating
system and device make CephX1 an efficient and practical tool to
be used.
Disclosure of interest
The authors declare that they have no competing interest.
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