Republic of Yemen

Sana’a University
Postgraduate Studies and Scientific Research
Faculty of Dentistry

Periodontology Department

Accuracy of Computerized Cephalometric Software In

Comparison With Manual Tracing In a group Yemeni
People in Sana’a City - Yemen

A research proposal submitted in partial fulfillment for the requirements of Master

degree in Orthodontics, Faculty of Dentistry, Sana’a University

Presented by
Saif-Aldeen Kareem Zughair
B. D. S. Faculty of dentistry
Dar Alssalam University – Yemen

Supervisor
Assistant. Prof. Dr. Rami Ishaq
Department of Orthodontic
Faculty of Dentistry
Sana’a University - Yemen

2021H
1443AD
 ‫الجمهورية اليمنية‬
‫جامعة صنعاء‬
‫نيابة الدراسات العليا والبحث العلمي‬
‫كلية طب االسنان قسم التقويم الثابت‬

‫كفاءة برامج السيفالومتري المحوسبة بالمقارنة مع التحليل بالرسم اليدوي في‬

‫عينة مختارة من مرضى التقويم‬

‫خطة بحث مقدمة استيفاءا لمتطلبات الحصول على درجة الماجستير في تقويم األسنان‬

‫مقدمة من الطالب‬

‫سيف الدين كريم زغير‬

‫بكالوريوس طب اسنان (‪)2013‬‬
‫جامعة دار السالم ‪ -‬اليمن‬

‫المشرف الرئيسي‬

‫الدكتور‪ /‬رامي إسحاق‬

‫أستاذ تقويم األسنان المساعد‬
‫كلية طب االسنان ‪ -‬جامعة صنعاء‬

‫‪1443‬هـ‬

‫‪ 2021‬م‬
Accuracy of Computerized Cephalometric Software In
Comparison With Manual Tracing In a group Yemeni
People in Sana’a City - Yemen

1. Background:

1.1. Introduction:

Cephalometric is a compound latin word includes two distinct terms: cephalo (the

head), and metrics (measurements) (Barnhart, 1990).

Thus, cephalometry is the art of the human head measurements which used to evaluate

craniofacial growth. Skull radiographs is involved widely to measure the human head

dimensions since several years ago (STEINER, 1953).

Cephalometrics literally "head measuring" is the recording and interpretation of

measurements of the skull made on standardized radiographs of the living head.

Since the introduction of cephalometry by Broadbent and Hofrath in the 1930s

(Broadbent, 1931) (Hofrath, 1931)

the cephalometric technique has been regarded as a most important tool for

orthodontists and maxillo-facial surgeons engaged in studying dental malocclusions

and the underlying skeletal discrepancies.

Maxillofacial surgery, and orthodontics uses X-ray images to mark specific point on

skull to obtain the various angular and linear parameters (Delaire, 1997).

those points called cephalometric landmark which identified as set of feature in both

hard and soft tissue of the skull. Landmarks are employed to measure the cephalometric

components as distance in millimetres, and angles in degree (Delaire, 1997).

Landmarks are common anatomical points in human skeleton as represented in Fig. 1.

There are nearly 20 to 30 landmarks on the human skull which used widely in

cephalometric measurement (Daskalogiannakis et al., 2000).

The computer development has had a tremendous influence on individuals and society

in all aspects of daily life such as the medical area, the economy, education and

communication just to mention a few.

It has become an invaluable work tool, and orthodontics is not the exception because

in the last 30 years there has been an expansion the ough the development of

cephalometric programs to make a diagnosis, a treatment plan and maintenance of the

records in a digital form (Bearn & Lowe, 2001).

The arrival of the digital systems for taking radiographs has been of great help to

promote the use of the cephalometric programs in orthodontics in a more

straightforward way. Earlier conventional X-ray had to be manipulated to turn them

into a digital image through professional scanners to obtain a good image of the

anatomical structures thus avoiding distortion for an excellent digital tracing (Morales,

2005).

This study aimed to compare the error in cephalometric measurements with manual and

computerized methods using the softwares EZortho software program and Orthovision

software program, aiming to evaluate the reliability of cephalometrics techniques

analyzed.

This study aimed to evaluate the accuracy of manual cephalometrics compared to 2

specific softwares and quantified the degree of reliability of identification of

cephalometric points manually and digitally, evaluating and comparing the outcomes

achieved and comparing them to each other, to aid the clinician in selecting the best

option for cephalometrics, either manual or computerized.

 Figure 1 Cephalometric Landmark Points

Figure 2. Tracing on the Orthovision software program.

Figure 3. Tracing on the EZortho software program.

 Figure 4. Manual tracing

1.2. Statement of Problem:

The absence of local parameters to comparison between the computerized

cephalometric analysis and the manual tracing in Yemen , this study will investigate

this comparison through both manual tracing and computerized cephalometric analysis

programs, among Yemeni population in Sana’a city.

 1.3. Justification:

Worldwide, there are many systems to determind the Efficiency Of Computerized

Cephalometric Analysis In comparison With Manual Tracing, no consensus exists of

this comparison among Yemeni population. Therefore, this will be selected as a theme

of the study.

1.4. Aim of the study:

The main aim of this study is to compare the measurements made using

computerized cephalometric tracing software with manual measurements, with the

purpose of establishing the level of agreement between them in a section of Yemeni

population.

This study aimed to evaluate the reliability of manual cephalometrics compared to

two specific softwares and quantified the degree of reliability of identification of

cephalometric points manually and digitally, evaluating and comparing the outcomes

achieved and comparing them to each other, to aid the clinician in selecting the best

option for cephalometrics, either manual or computerized.

1.5. Specific aims:

The Specific aims of this study are to:

 Compare Efficiency Of Computerized Cephalometric Analysis (EZortho

software program)With Manual Tracing.

 Compare Efficiency Of Computerized Cephalometric Analysis (orthovision

software program)With Manual Tracing.

 Compare Efficiency Of Computerized Cephalometric Analysis (orthovision

 software program)With (orthovision software program).

1.6. Hypothesis:

There is no difference in the reliability Computerized Cephalometric Analysis

compared With manual Tracing, among some of Yemeni population in Sana’a city –

Yemen. Through an analytical study, we will verifying this hypothesis.

2. Review of Literature :

2.1 Introduction of Cephalometric

Silling et al (Silling et al., 1979). stressed that LCR was only needed for Class II

division 1 patients. Later, Han et al (Han et al., 1991) stated that patient examination

together with dental casts provided sufficient information with which to render a

diagnosis.

According to them, only 55% of treatment plans were changed after LCR

evaluation. In the same vein, Bruks et al (Bruks et al., 1999) suggested that in 93% of

the cases treatment plans remained unchanged after LCR evaluation. They evaluated

the patient, dental casts, and extraoral photographs.

Technical advances in computer science have made it possible to perform

cephalometric tracing both through the use of digitizers and directly on screen-

displayed digital images.

First-generation computer-based analysis systems used digitizer pads for tracing

conventional cephalometric films and software programs to compute the

6
7
measurements, whereas second-generation systems use scanners or digital cameras to

export cephalometric images to measurement programs.

Recently, third-generation systems have been introduced that transmit digital

radiographs directly to a computer database through the use of photostimulable

phosphor plates, charge-coupled device receptors, or direct digital systems.

The use of direct digital images offers several advantages, such as instant image

acquisition, reduction of radiation dose, facilitated image enhancement and archiving,

elimination of technique-sensitive developing processes, and facilitated image sharing

( Quintero et al. , 1999; Brannan, 2002 ).

2.2 Manual Tracing

Applications for cephalometric analysis include case diagnosis, treatment planning,

prediction of growth and the evaluation of treatment results (Steiner, 1960).

Manual tracing of cephalometric Alms is performed by identifying radio-graphic

landmarks on acetate overlays and using these reference points to construct lines, planes

and angles to enable the measurement of linear and angular values, using a millimetre

scale and a protractor. This manual process can be time-consuming and the

measurements obtained may be subject to error. Whilst advances in computer science

have led to the widespread application of computers in cephalometry (Rudolph et al.,

1998)

offering enhanced accuracy, nevertheless, the skills of manual analysis are still

required.

Conventional cephalometric analysis is performed by tracing radiographic landmarks

on acetate overlays and measuring linear and angular values.

 Despite its widespread use in orthodontics, the technique is time-consuming and

has the disadvantage of being subject to random and systematic error. The main sources

of errors include technical measurements, radiographic acquisition and identifying

landmarks.

Most error soccur in landmark identification and are influenced by clinician experience,

landmark definition, image density and sharpness (Cohen, 1984) (Sandler, 1988)

The reduction of a three-dimensional(3D) structure to a two-dimensional (2D) image

adds to the difficulty (Santoro et al., 2006).

Digital Tracing

With the rapid evolution of computer radiography,digital tracing has slowly

replaced the manual tracing methods. Three techniques are commonly

reported(Polat-Ozsoy et al., 2009).

the first uses digitizer pads for tracing conventional cephalometric films and

software programs to compute the measurements; the second uses scanners or

digital cameras to export cephalometric images to measurement programs; and the

third transmits digital radio-graphs directly to a computer database. The use of both

digital radiography and conversion of manual film to a digital format offers several

advantages it is easyto use, allows several analyses to be performed at a time,

promises convenience when generating treatment predictions (Ongkosuwito et al.,

2002), takes up less storage space(Vincent & West, 1987),

allows superimposition of images,(Forsyth & Davis, 1996) provides the option to

manipulate the size and contrast of the image and provides the ability to archive and

improve access to images to overcome the problem of film deterioration,which has

 been a major source of information loss incraniofacial biology (Santoro et al., 2006)

(Sayinsu et al., 2007).

Computerized cephalometric analysis may use either a manual or an automatic

identification of landmarks. Automated systems at present are unable to compete

with manual identification in terms of accuracy of landmark position.

The landmarks lying on the poorly defined structures are difficult to automatically

identify.(Forsyth et al., 1996)

With the development of computer technology, digital tracing has become

possible. Two techniques are commonly used to produce digital tracings of

radiographs. The first uses a charge-coupled device sensor (direct digitization).

The digital image is produced instantaneously, without additional processing. The

second method uses storage phosphor plates to capture the image (indirect

digitization). The plates store the radiation energy generated by the radiographic

apparatus in a latent image which is then transferred by a red laser scanner to the

computer in digital format. The computer images from either method consist of a

collection of pixels, whose size and colour values produce different colours and

shades of grey. The final size of the image is determined by the number and

colour values of its pixels (Santoro et al., 2006)

2.3 Comparison Between Manual and Digital Tracing

The manual method is not only time-consuming but also allows more measurement

errors caused by doctors. The reproducibility of cephalometric points in conventional

method on paper in comparison to the analysis of digital image was controversial for a

long time. The complicated process to obtain a digital record of X-ray, loss of data

during digitization resulting in reduced quality of the image, or complicated and not
sufficiently tested software analysis disputable in the past (Thurzo et al., 2010).

Nowadays, due to the technology advancement and necessity of data mobility, the

manual method is becoming a handicap. Nowadays, digitizing X-rays has become the

preferred method to perform cephalometric measurements. As technology evolves, it

becomes increasingly easier for professionals to adapt to the many routine tasks of

clinical practice (Paixão et al., 2010).

Various computer programs have been developed in recent years for cephalometric

analysis. Previous studies have evaluated systems such as the Dentofacial Planner, the

Dolphin Imaging, and the Quick Ceph®. The common conclusion of these studies

was that although differences between computer prediction and manual tracing are not

in some cases statistically significant, they can be clinically significant in others.

Some landmark locations and measurements (SNA, Wits, E-plane, soft tissue point B,

gonion, points articulare) were more reproducible with manual tracing while other

points (e.g. the apex of the upper incisor root) were easier to locate with digital tracing

(Gerbo et al., 1997); Csaszar et al. , 1994 ; Loh et al. , 2001 ; (Turner & Weerakone, 2001); (Ferreira &

Telles, 2002) (Loh & Yow, 2002); (Ongkosuwito et al., 2002); (Cousley et al., 2003); (Chen et al.,

2004) , b ; (Gossett et al., 2005); (Power et al., 2005); (Bruntz et al., 2006)).

A comparative study between the manual and computerized cephalometric

measurement methods was performed by Richardson (Richardson, 1981) in 1981.

He compared 50 lateral cranial radiographs of 12-year-old children, half male and half

female. Fourteen landmarks were defined in that study: S, N, anterior nasal spine,

subspinal, incisal and zenith of the maxillary incisor, incisal and zenith of the

maxillary incisor, supramenton, pogonion, gnathion, molar, pterygomaxillary and

articulare. The conclusion was that traditional methods were inferior in comparison to
digital procedures, but not alarmingly so, and in some cases traditional methods

produced more precise results.

As the use of computers in assisting cephalometric analysis gained popularity, both in

research and in clinical applications, Nimkarn and Miles (Nimkarn & Miles, 1995)

studied the reliability of computer assisted cephalometrics in 1995. Forty radiographs

from the same x-ray machine were used and chosen at random. Each radiograph was

traced in acetate paper, and the images of the radiographs and tracings were captured

in a video camera, projected onto a monitor, where the landmarks were digitized. The

cephalometric measurements were obtained using Quick Ceph 5.1 software (Quick

Ceph Systems, USA).

The program performed the calculations for all 40 measurements, from 22 marked

landmarks. In order to assess methodology errors and identify the source of errors, the

study consisted of five parts: 1) Reproducibility of computerized measurement

technique; 2) Video imaging, digitalization and software; 3) Digitalization and

software; 4) Computer vs. manual measurement; 5) Software calibration and operator

digitalization errors. The results showed that the measurements performed in the

computer were comparable to manual measurements, with no statistically significant

differences.

One study involving two orthodontists, who each twice traced 21 cephalometric

landmarks in 100 radiographs obtained through the traditional method and 100

radiographs obtained from digital imaging, demonstrated a coincidence in intra

observer cephalometric landmarks and little inter observer difference (Hagemann et

al., 2000).
The authors also highlighted that the linear and angular measurements were more

precise in the digitally obtained radiographs, emphasizing that the quality of digital

radiographs facilitates cephalometric measurements(Hagemann et al., 2000).

Also a comparative study between the manual and computerized cephalometric

measurement methods was performed by The Author(s) Mosleh, Mogeeb Ahmed

Ahmed Baba, Mohd Sapiyan Malek, Sorayya Almaktari, Rasheed A in 2016

Novel system named Ceph-X is developed to computerize the manual tasks of

orthodontics during cephalometric measurements.

Ceph-X was evaluated by using X-ray images of 30 subjects (male and female)

obtained from University of Malaya hospital , Statistical analysis for the comparison

between the manual and automatic cephalometric approaches showed that Ceph-X

achieved a great accuracy approximately 96.6%, with an acceptable errors variation

approximately less than 0.5 mm, and 1°. Results showed that Ceph-X increased the

specialist performance, and minimized the processing time to obtain cephalometric

measurements of human skull.(Mosleh et al., 2016)

 3. Materials And Methods:

3.1. Study Design :

The study will be cross-sectional observational study among Yemeni population in

Sana’a city – Yemen, to evaluate the existence comparison between computerized

Cephalometric Analysis, With Manual Tracing.

Manual method

All the lateral cephalograms were traced using a sheet of acetate tracing paper. The

tracings were done on a view box with the tracing paper securely positioned over the

radiograph with a masking tape. Once the landmarks were traced, the lines and planes

were obtained.

Digital method

The digital image of each conventional lateral cephalogram was obtained by

transferring the selected images archives of the cephalogram folder to the orthovision

software program) and (orthovision software program). The cephalometric landmarks

were identified on the displayed image and digitalized on‑screen by the technician who

has 12 years experience with orthodontic specialists took place in experiments to

evaluate the accuracy and performance of the programs , and the lines and planes were

obtained by the program automatically .

 3.2. Study Population :

 Two different software program for computerized Cephalometric Analysis, will be

get from tow privet X-ray center in Sana’a city.

 Well manual tracing for the same cephalometric x-ray will be done by the

researcher.

 The data will be collected by a specific program then analysis by SPSS software

program, version 19 manufactured by IBM, Chicago Illinois USA.

3.3. Sample Size :

The study sample are calculated by using open epi® software, where the prevalence

≤ 0.05, confidence interval 95% , the minimal calculating sample size are 90 x-ray for

the participants.

3.4. Data Collection :

General information (personal information, age and gender) will be obtained from

an X-ray center.

A standardized manual tracing and computerized analysis for each cephalometric x-

ray, as follows:

The anatomical landmarks were chosen :- S (sella turcica), N (nasion), A (subspinale),

B (supramentale), Gn (gnathion), and Go (gonion) , Posterior nasal spine (PNS) ,

Anterior nasal spine (ANS) , Menton (Me)

The skeletal cephalometric measurements :- SNA, SNB, ANB, Ant. cranial base ,

Post. cranial base

the dental cephalometric measurements :- Mx1 to NA , Mx1 to NA , Mn1 to NB ,

Mn1 to NB , Mx 1 to SN , Interincisal angle

And the soft tissue cephalometric measurements :- Esthetic line to upper lip (mm) ,

Esthetic line to lower lip (mm)

3.5. Data Management And Analysis :

All data will be collects then analyze by SPSS software, version 19 manufactured by

IBM, Chicago Illinois USA, corporation is use to perform the statistical analysis. A

statistical value of <0.05 is deem to be significant.

3.6. Management :

The Proposal Schedule will start from september, 2021 up to collect final number of

participants.

4. Ethical Considerations :

Approval for the study will be applied for the Ethical Committee of Sana’a University

,faculty of dentistry in Yemen.

5. Budget Summary :

All costs including equipment’s , data collection and data processing will be a self
funding .

Objectives No. Cost Properties

1 Laptop 1 1500$ LENOVO Y520 series

2 External hard 1 100$ 1TB

disk

3 USB 1 25$ 132 GB

4 Analysis 2 1000$
programs
rental

5 Others --- 1500$ Analysis, Transport, print

….etc

Total 4200$
 6. Timelines (2020/2021):

2021 2022
Step/Months Dec.
Oct. Nov. Jen. Feb. Mar. Apr. May. Jun. Jul. Aug. Sep.

Protocol

Computerized
analysis

Manual
Analysis

Writing

Presentation of
final research
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