TECHNO BYTES

Construction of orthodontic setup models

on a computer
Takuya Kihara,a Kotaro Tanimoto,b Masahiko Michida,c Yuki Yoshimi,c Toshikazu Nagasaki,d
Takeshi Murayama,e Kazuo Tanne,f and Hiroki Nikawae
Hiroshima, Japan

Introduction: Orthodontic setup models are usually limited to the display of teeth, with no information about the
roots. The purpose of this article is to present a method for visualizing the tooth roots in setup models by inte-
grating information from cone-beam computed tomography and a laser scanner. The reproducibility of the
integration was evaluated. Methods: The records of 5 patients were used in this study. Three-dimensional
digital models were generated from the dental casts. Tooth models were generated from the cone-beam
computed tomography slices. The 3-dimensional models were superimposed on the crowns of the teeth in
the tooth models and integrated. The integrated 3-dimensional tooth model and 3-dimensional setup model
were registered. The reproducibility of the integration was evaluated for each tooth. Unpaired Student t tests
were performed on the data between the anterior and posterior teeth, and between the right and left teeth.
Results: The discrepancy among the integrated 3-dimensional models at the final positions after we used
this technique was 0.025 6 0.007 mm. There was a significant difference in the distance between the
anterior and posterior teeth (P \0.05). However, the average distances between the anterior and posterior
teeth were small: 0.023 6 0.007 and 0.028 6 0.007 mm, respectively. No significant difference was found
between the right and left teeth (P 5 0.831). Conclusions: The methods presented in this study provide a repro-
ducible visualization of tooth roots in virtual setup models by registering accurate crown models to cone-beam
computed tomography scans. (Am J Orthod Dentofacial Orthop 2012;141:806-13)

T
he goal of orthodontic treatment is to improve the
malocclusion and the relevant functions of the or-
ofacial system. Successful orthodontic treatment
should be based on extensive diagnosis and treatment
planning. Essential information for diagnosis is obtained
from dental casts, photographs, and radiographs. In ad-
dition, the setup model, which is used to predict tooth
alignment after treatment, is also useful for diagnosis
and plays an important role in the 3-dimensional (3D)
From the Graduate School of Biomedical Sciences, Hiroshima University, Hirosh-
ima, Japan.
a
Postgraduate student, Department of Oral Biology and Engineering, Division of
Oral Health Sciences.
b
Lecturer, Department of Orthodontics and Craniofacial Developmental Biology.
c
Postgraduate student, Department of Orthodontics and Craniofacial Develop-
mental Biology.
d
Assistant professor, Department of Oral and Maxillofacial Radiology.
e
Professor, Department of Oral Biology and Engineering, Division of Oral Health
Sciences.
f
Professor, Department of Orthodontics and Craniofacial Developmental Biology.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Hiroki Nikawa, 1-2-3, Kasumi, Minami-ku, Hiroshima
734-8553, Japan; e-mail, hirocky@hiroshima-u.ac.jp.
Submitted, April 2011; revised and accepted, October 2011.
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.10.027
806
diagnosis.1 Currently, the setup model is often limited
to showing the alignment of the crowns, with no infor-
mation regarding the morphology or the direction of the
roots or the surrounding bone. Accordingly, root resorp-
tion and fenestration of cortical bone might be due to
mutual interference between tooth roots and cortical
bone and compression of cortical bone.2 Therefore,
orthodontists must make diagnoses and treatment-
planning decisions with special attention not only to in-
dividual crowns but also to the roots and craniofacial
structures. A system for visualizing tooth roots might
be useful for observing the positional relationships be-
tween the tooth roots and the alveolar bone. Moreover,
clinicians could check root parallelism easily in the setup
model.
Three-dimensional technology has generated exten-
sive fields of application in dentistry.3-5 In orthodontics,
various studies have demonstrated automatic tooth
alignment,6,7 quantitative evaluations for tooth move-
ment,8-12 and facial profile13-15 and stress analyses.16
Some research groups have attempted to integrate 2 dif-
ferent structures.17,18 Macchi et al19 reported a method
to represent complete 3D views of the maxilla, the
mandible, and the setup model with individual anatomic
roots with conventional computed tomography.
Kihara et al
Although their method is ideal, computed tomography
has some limitations in dentistry because of its high
cost, low vertical resolution, and high dose of radiation.
Recently, cone-beam computed tomography has
become more widely used in dental clinics to obtain
3D images.20,21 The radiation dosage is considerably
lower with cone-beam computed tomography than in
conventional computed tomography scanning.22,23
Cone-beam computed tomography also has other ad-
vantages, including shorter acquisition times and re-
duced costs. Although the precision of the tooth crown
on cone-beam computed tomographs is low, this disad-
vantage would be offset by integrating the tooth crown
of the dental cast with that of the cone-beam computed
tomographs. However, to our knowledge, the recon-
struction of tooth roots from cone-beam computed
tomography scans and superimposition of the dental
cast and the setup model has not yet been reported.
Moreover, no reports have been published on the repro-
ducibility of superimposition.
The purposes of this study were to establish a method
for visualization of the tooth roots in a setup model
with cone-beam computed tomography and noncontact
3D scanning, and to assess the reproducibility of this
method.
MATERIAL AND METHODS
Dental casts and cone-beam computed tomography
slices were obtained from 5 patients (1 male, 4 female)
who were diagnosed with maxillary canine impaction
and preparing for treatment at the Department of Ortho-
dontics at Hiroshima University Hospital in Japan. Their
ages ranged from 15 to 25 years. This study was
approved by the Ethical Committee for Epidemiology
of Hiroshima University (number 329).
Figure 1 shows the algorithm for visualization of the
tooth roots in the setup model. The procedure consists of
4 stages: (1) acquisition of the 3D dental cast model, (2)
reconstruction of the 3D cone-beam computed tomog-
raphy tooth model, (3) integration of the 3D dental cast
model with the 3D cone-beam computed tomography
tooth model, and (4) visualization of the tooth roots in
the setup model and the surrounding bone. The details
of each step are described below.
The surface of the dental cast obtained from each pa-
tient’s dentition was archived by means of a noncontact
3D surface scanner (RexcanDS, Solutionix, Seoul, Korea)
to create the corresponding 3D dental cast model. The
RexcanDS measuring system is based on the principle
of a phase-shifting optical triangulation. An object is
scanned with halogen light stripes, and the twin cameras
receive the light reflected from the surface of object
American Journal of Orthodontics and Dentofacial Orthopedics
807
(Fig 2). RexcanDS has a reported manufacturing accu-
racy of 0.016 mm. The generated 3D dental cast model
was exported to the stereolithography format containing
the 3D coordinates. The stereolithography format is
a polygon mesh and list of the triangular surfaces that
describes the generated 3D model.
Cone-beam computed tomography (CB MercuRay,
Hitachi Medical, Tokyo, Japan) images taken of the pa-
tients previously for their orthodontic treatment were
used. The isotropic voxel size was 0.1 mm (D-mode,
120 kV, 15 mA) for this device. Scanning time was 9.6
seconds. All slice data were exported with the digital im-
aging and communication in medicine (DICOM) format.
Since all cone-beam computed tomography images used
in this study were taken for diagnosis of the maxillary
impacted teeth in these orthodontic patients, the mea-
sured area of the cone-beam computed tomography
was focused on the maxilla and did not cover the whole
maxilla and mandible. The 3D cone-beam computed to-
mography tooth models consisting of the teeth includ-
ing the roots were segmented and reconstructed with
ZedView software (LEXI, Tokyo, Japan). Segmentation
refers to the manual process of outlining and masking
the shape of structures visible in the cross-sections of
volumetric data. The difficulty of segmenting the teeth
from cone-beam computed tomography data is attrib-
uted to their similarity in intensity with the surrounding
bone. It took approximately 2 hours on average for the
segmentation of the cone-beam computed tomography
tooth model with manual outlining. The generated 3D
cone-beam computed tomography model was exported
to the stereolithography format containing the 3D coor-
dinates.
The data from the 3D dental cast model and the 3D
cone-beam computed tomography tooth model were
imported with stereolithography format on the same
3D coordinates by using reverse modeling software
(RapidForm 2006; INUS Technology, Seoul, Korea). Rap-
idForm 2006 enables data processing and analysis such
as cutting, displacement, and calculation of distances.
To superimpose the 3D dental cast model on the 3D
cone-beam computed tomography tooth model, the
crown of each tooth was used as the index of superim-
position. This surface-to-surface matching used the iter-
ative closest point algorithm as a function of RapidForm
2006. The iterative closest point algorithm finds the
transformation that brings a model into the best possible
alignment with the other model by iteration.11
It is desirable that the crowns of the teeth and the
setup model are the same form for superimposing
the teeth onto the setup model. However, the crowns
of the 3D dental cast model have superior reproducibility
compared with the 3D cone-beam computed
June 2012  Vol 141  Issue 6
808 Kihara et al

Fig 1. An algorithm for the visualization of tooth roots in the setup model.

tomography tooth model. Thus, the crowns were elimi-

nated from the 3D cone-beam computed tomography
tooth model and merged with the crown of the 3D dental
cast model with software (FreeForm, SensAble Technol-
ogies, Woburn, Mass) (Fig 3, A). Integration of the 3D
dental cast model with the 3D cone-beam computed to-
mography tooth model was completed (the integrated
tooth 3D model) (Fig 3, B).
In general, a setup model consists of the teeth made
of plaster and paraffin wax to fix the teeth. The setup 3D
model was generated in the same way, acquiring the 3D
dental cast model with the RexcanDS. The 3D tooth in-
formation was transferred from the integrated 3D tooth
model to the setup 3D model by using the RapidForm
2006. Moreover, the surrounding bone 3D model was
segmented and reconstructed with ZedView and super-
imposed on the integrated 3D tooth model. Accordingly,
Fig 2. The principle of a phase-shifting optical triangula-
the teeth in a setup model can be observed with the sur- tion. CCD, Charge-coupled device.
rounding bone displayed.
Reproducibility of the technique was evaluated with included the average distance and the standard devia-
RapidForm 2006. The technique was performed in trip- tion among the integrated 3D tooth models at the final
licate, and the discrepancy among the integrated tooth positions with this technique.
3D models at the final positions after this technique The reproducibility of superimposition might be im-
was calculated with a shell-to-shell deviation map as portant, but the dimension of any discrepancy would be
the intraexaminer error. A shell-to-shell deviation map expected to depend on the site or region of the dentition.
calculates a distance in whole 3D models between each Thus, unpaired Student t tests were carried out on the
point on the 3D model and the nearest neighbor point data between the anterior and posterior teeth, and
on another 3D model (Fig 4). The calculation was between the right and left teeth with SPSS software
computed and automatically completed. The results (version 15.0J; SPSS Japan, Tokyo, Japan).

June 2012  Vol 141  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Kihara et al 809

Fig 3. A, Integration of the 3D dental cast model with the 3D cone-beam computed tomography teeth
model with FreeForm; B, the integrated 3D tooth model.

RESULTS difference in the distance between the anterior and pos-

The results of the registration for a patient are shown
in Figure 5. For all 5 patients, the tooth roots did not
protrude outside the surface of the mucosa and the
bone. Also, the tooth roots of the setup models were
parallel.
The average distance between the integrated 3D
tooth models at the final positions after we used this
technique was 0.025 6 0.007 mm. Figure 6, A, shows
the reproducibility of this technique for the anterior
and posterior teeth. The average distances of the anterior
and posterior teeth were 0.023 6 0.007 and 0.028 6
0.007 mm, respectively. There was a significant
terior teeth (P \0.05). Figure 6, B, shows the reproduc-
ibility of the technique on the right and left teeth. The
average distances of the right and left teeth were
0.026 6 0.007 and 0.024 6 0.007 mm, respectively.
There was no significant difference in the distance
between the right and left teeth (P 5 0.831).
DISCUSSION
In this study, a method to visualize tooth roots and
surrounding bone in a setup model was demonstrated;
it uses a 3D model reconstructed from cone-beam com-
puted tomography. In addition, the reproducibility of

American Journal of Orthodontics and Dentofacial Orthopedics June 2012  Vol 141  Issue 6
810
Fig 4. Distance between each point on the 3D model and the nearest neighbor point on another 3D
model.
this technique was assessed. Since this approach allows
visualization of the tooth roots, it could provide useful
insights that could lead to more precise fabrication of
the setup model.
With the automatic scan function, the RexcanDS
used for the measurement of dental casts set the opti-
mum path and several values of swing and rotation at
that stage, and automatically measured an object of
similar shape by using the previously saved path. Fur-
thermore, it was also possible to measure objects conve-
niently by automatically carrying out registrations
without a matching marker attached, and it requires
no separate data postprocessing. Accordingly, the whole
shape was measured and generated easily. The 3D dental
cast model could be generated accurately and used as an
alternative to dental casts.10,24,25
The scattered radiation of cone-beam computed
tomography is greater than conventional computed to-
mography because of the plane detector of the cone-
beam computed tomography. Several artefacts such as
beam hardening, truncation, and inhomogeneity influ-
ence model contrast and bone border definition in
cone-beam computed tomography.26 Thus, human in-
tervention was needed to separate the teeth manually
from the surrounding bone because cone-beam com-
puted tomography has no computed tomography value,
and the tooth model has vague boundaries at certain
cross sections. Reproducibility of the tooth could not
be evaluated in this study because the subjects were pa-
tients who were undergoing orthodontic treatment. In
terms of reproducibility of the teeth from cone-beam
computed tomography, Baumgaertel et al27 found no
significant difference in the measurements between
the cone-beam computed tomography images and the
anatomic structures. Liu et al28 demonstrated that the
June 2012  Vol 141  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Kihara et al
in-vivo differences in tooth volumes between cone-
beam computed tomography and the actual tooth vol-
ume were –4% to 7%, and these data would not be likely
to influence the study model analysis for diagnosis and
treatment planning. Therefore, in this study, the 3D
cone-beam computed tomography tooth model was
considered to reproduce the patients’ tooth morphology
with sufficient precision. Furthermore, if patients’
maxillary and mandibular teeth are in close contact, seg-
mentation of the occlusal surfaces of the teeth from
cone-beam computed tomography might be difficult.
In this case, a thin wax bite is used during the cone-
beam computed tomography scan as a countermeasure.
We want to address this point in a future study.
The 3D dental cast model and the 3D cone-beam
computed tomography tooth model were positioned dif-
ferently on the 3D coordinate system because of different
acquisition methods. Accordingly, the 3D dental cast
model and the 3D cone-beam computed tomography
tooth model were superimposed on the crowns of the
teeth, and the gap between the 2 models was minimized.
Several studies have used fiducial markers as the
main registration tool for the integration of 3D models
from computed tomography and a 3D scanner.18,29
However, some practical problems remain that are
relevant to the clinical setting because of its complexity
involving multilevel processes. Thus, the integration of
3D models by markerless registration might be needed.
Kim et al17 found that the average differences between
patients’ digital dental and maxillofacial models
were 0.12 mm for the maxilla and 0.13 mm for the man-
dible by a point-based and surface-based markerless
registration.
To improve the reproducibility of the 3D cone-beam
computed tomography tooth model, the 3D dental cast
Kihara et al
Fig 5. The 3D teeth of the dental cast (left) and the setup
model (right) for a patient.
model and the 3D cone-beam computed tomography
tooth model should be merged to generate an integrated
3D tooth model with almost the same crowns as the
setup model. The junction of the integrated 3D tooth
model was deformed slightly, but the crowns and roots
were not obviously deformed. Therefore, this potential
error did not affect the next step.
It is impossible to capture the gingival area in the
setup model correctly with a phase-shifting optical tri-
angulation because halogen light stripes used to recon-
struct a 3D model interfere with light reflection in the
lenses with paraffin wax. The gingival area can be cap-
tured if a special powder is applied on this area, but
American Journal of Orthodontics and Dentofacial Orthopedics
811
Fig 6. Reproducibility: A, anterior and posterior teeth
(*P \0.05); B, right and left teeth.
this was not done in this study because the method of
visualization could be carried out. The teeth in the setup
3D model have same shape as the 3D dental cast model
because the setup model was fabricated by using the
teeth of the pretreatment dental cast, with only a small
error.
The reproducibility of this method calculated with
a shell-to-shell deviation map would be acceptable for
clinical use in orthodontics.30 The reasonable value
that is acceptable is considered to be 0.1 mm or less be-
cause of the fabrication order for the setup model. The
significant difference in the reproducibility between
the anterior and posterior teeth might be caused by de-
formation of the impression and the dental cast. Another
reason might be the reproducibility of cone-beam com-
puted tomography or the segmentation of the teeth. No
June 2012  Vol 141  Issue 6
812
significant difference in the reproducibility between the
right and left teeth indicates that the superimposing
function with RapidForm 2006 is stable and has a favor-
able balance. Because of our technical limitations at this
time, the occlusion could not be simulated in the setup
model by using cone-beam computed tomography in
this study. However, 3D technology has been applied
in several previous studies on the occlusion of pa-
tients.31,32 Thus, the setup model could also represent
the occlusion.
In addition, there are various advantages in this tech-
nique for 3D models. Plaster models require physical
space for storage, adding financial and logistic burdens.
The electronic storage of a patients’ dental casts as 3D
models will eliminate the problems of storage, retrieval,
and maintenance of the casts; office management; and
communication between the various specialties, thus al-
lowing for easier consultations.33
Clinicians would be able to check the parallelism of
the tooth axis during orthodontic treatment via the
root visualizing system without additional cone-beam
computed tomography scans. This is because the 3D
data taken from the tooth crowns of the study cast
can be integrated with the 3D data of the tooth roots.
Therefore, this method would provide additional infor-
mation on the tooth roots without exposing the patient
to additional radiation.
CONCLUSIONS
It is feasible to visualize tooth roots in a setup model
from dental cast and cone-beam computed tomography
data. The method provides sufficient reproducibility to
visualize tooth roots in a setup model and allows clini-
cians to easily observe the relationship of the tooth roots
in a setup model and the surrounding tissues.
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