TECHNO BYTES

Measurement of the buccolingual inclination

of teeth: Manual technique vs 3-dimensional
software
Mahtab Nouri,a Amir Hossein Abdi,b Arash Farzan,c Faraneh Mokhtarpour,d and AliReza Akbarzadeh Baghbane
Tehran and Babol, Iran

Introduction: In this study, we aimed to measure the inclination of teeth on dental casts by a manual technique
with the tooth inclination protractor (TIP; MBI, Newport, United Kingdom) and a newly designed 3-dimensional
(3D) software program. The correlation of the 2 techniques was evaluated, and the reliability of each technique
was assessed separately. Methods: This study was conducted on 36 dental casts of normal, well-aligned
Class I occlusions; we assessed 432 teeth. All casts had a normal Class I occlusion. After determining the
facial axis of the clinical crown and the facial axis points on the dental casts, we measured the inclinations
of the incisors and posterior teeth up to the first molars in each dental arch relative to Andrews' occlusal
plane and the posterior occlusal plane using the TIP. Moreover, the casts were scanned by a structured-
light 3D scanner. The inclination of teeth relative to the occlusal plane was determined using the new
software. To assess the reliability, measurements of all teeth from 15 casts were repeated twice by the 2
methods. Intraclass correlation coefficient and Dahlberg's formula were used for calculation of correlation
and reliability. Results: Overall, the 2 techniques were not significantly different in the measurements of
the inclinations of the teeth in both jaws. The ranges of Dahlberg's formula were 3.1 to 5.8 for the maxilla
and 3.3 to 5.9 for the mandible. The overall correlation of the 2 techniques according to the intraclass cor-
relation coefficient was 0.91. For calculation of reliability, the intraclass correlation coefficients for the TIP
and the 3D method were 0.73 and 0.82, respectively. Conclusions: The TIP and the 3D software showed
a high correlation for measurement of the inclinations of maxillary and mandibular teeth relative to the occlusal
plane. Also, the reproducibility of the measurements in each method was high. (Am J Orthod Dentofacial
Orthop 2014;146:522-9)

T
he inclination of anterior teeth is an extremely
important factor in smile esthetics. It has been
introduced as 1 of the 6 keys of occlusion by An-
drews.1 Moreover, it is a fundamental parameter in
determination of the prescription of preadjusted ortho-
dontic appliances.2 Two issues are important for the
measurement of tooth inclination: the measurement
tool and the defined landmarks. Several tools have
been used for this purpose: cephalometric angular
measurements,3,4 conveyor and compass on dental
casts,5 the tooth inclination protractor (TIP; MBI, New-
port, United Kingdom) on the casts6 or intraorally,7 and
3-dimensional (3D) methods including angular mea-
surements on 3D cast models8-14 or cone-beam
computed tomography (CBCT).15,16 An accurate error-
free technique for this purpose has yet to be found.
However, the TIP has been demonstrated to be an inex-
pensive, easy-to-use, noninvasive, and reliable method

a
Associate professor, Dentofacial Deformities Research Center, Research Institute
of Dental Sciences, and Department of Orthodontics, School of Dentistry, Shahid
Beheshti University of Medical Sciences, Tehran, Iran.
b
Research assistant, Computer Engineering Department, Sharif University of
Technology, and School of Dentistry, Shahid Beheshti University of Medical Sci-
ences, Tehran, Iran.
c
Postgraduate student, Department of Orthodontics, Dental Research Center,
Research Institute of Dental Sciences, Shahid Beheshti University of Medical
Sciences, Tehran, Iran.
d
Postgraduate student, Department of Operative Dentistry, School of Dentistry,
Babol University of Medical Sciences, Babol, Iran.
e
Associate professor, Department of Basic Sciences, School of Rehabilitation,
Shahid Beheshti University of Medical Sciences, Tehran, Iran.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
This study was based on an undergraduate thesis by Faraneh Mokhtarpour and
supervised by Mahtab Nouri at the Dental School of Shahid Beheshti University
of Medical Sciences. It was funded by the Dentofacial Deformity Research
Center, Research Institute of Dental Sciences, Shahid Beheshti University of
Medical Sciences, grant no. 419/326.
Address correspondence to: Arash Farzan, Department of Orthodontics, School
of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran;
e-mail, dr.arash.farzan@gmail.com.
Submitted, February 2014; revised and accepted, June 2014.
0889-5406/$36.00
Copyright Ó 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.06.018

522
Nouri et al
for measuring incisor crown inclination.6,7 Moreover, 3D
techniques have high reliability and accuracy for such
angular measurements.10,14
Landmarks used for measuring tooth inclinations are
different in lateral cephalograms, cast measurements,
3D models, and 3D imaging (CBCT). In 2-dimensional
and 3D radiographic techniques, the long axis of the
tooth has been used3,4,16; in cast-based or intraoral
measurements, the facial axis of the clinical crown has
been used.5 Moreover, different horizontal reference
planes have been used in various studies. Cephalometric
methods use palatal, mandibular, and occlusal refer-
ence planes.3,4 Andrews1 used an occlusal plane that
was approximated with a plastic template. This tem-
plate was in contact with the anterior and posterior
teeth.5,17 He used this method for measuring tooth
inclination represented by tip and torque. Ross et al18
introduced the posterior occlusal plane for measuring
the inclination of posterior teeth. This plane was
tangent with the most occlusal cusp points in both first
molars, and 1 or 2 premolars. Richmond et al6 used their
own invented device, the TIP, with an occlusal plane
similar to that of Andrews. In the 3D cast-based
methods and radiography, different reference planes
have been used.14,16 Overall, changes in the horizontal
reference plane compromise the validity of different
methods for measuring tooth inclinations (relative to
one another, or at different treatment phases).
However, this plane might have a minimal impact on
reliability.6
At present, modern 3D digital technologies make
such measurements easily possible in a short time and
with high accuracy. Furthermore, software programs
have been developed for 3D analysis of dental casts
used for diagnosis of discrepancies, treatment planning,
and evaluation of changes as a result of treatment. These
software programs have the potential for measuring all 6
keys of ideal occlusion suggested by Andrews.11,14
Several manufacturers, such as Orthocad,19 Ortho-
proof,20 and O3DM,14 have introduced commercial soft-
ware programs for analyzing digital models and
measuring linear and angular parameters on 3D models.
Considering all the above, in this study we had the
following objectives: (1) to measure the inclinations of
the incisors, canines, premolars, and first molars on
dental casts using the TIP and a 3D software developed
at Shahid Beheshti Dental School in Tehran, Iran; (2) to
assess the correlations of the 2 techniques and the dis-
crepancies between measurements; and (3) to assess
the reliability of the 2 techniques.
The null hypothesis of the study was that no signifi-
cant correlation exists between measurements made
with the TIP and the computer software.
American Journal of Orthodontics and Dentofacial Orthopedics
523
MATERIAL AND METHODS
This study was conducted on 36 dental casts of
normal and well-aligned Class I occlusions (432 teeth).
The buccolingual inclinations of the incisors, canines,
premolars, and first molars (12 teeth in each cast) were
measured by the TIP and a 3D laser scanner. These
normal-occlusion casts were selected from the cast ar-
chives of Qazvin Dental School in Qazvin, Iran, using
convenience sampling.
We used the following tools. The TIP was used to
measure the inclinations of the anterior teeth, premolars,
and molars on the dental casts and in the mouth: this de-
vice has a horizontal plane, a conveyor, and a rod for
contact with the labial surfaces of the teeth for
measuring the axial inclination of the tooth crown. A
structured-light 3D scanner (Maestro3D Desktop Scan-
ner; AGE Solutions, Pontedera, Italy) was used for the
3D scanning of the dental casts with 10-mm readability.
The measurement technique was the following. First,
the locations of the facial axis points were marked on
each tooth with a fine-tip pencil (diameter, 0.5 mm) ac-
cording to the method of Andrews.1
For measuring the inclinations of the anterior teeth
with the TIP, the horizontal plane of the device was
placed in contact with the occlusal plane, as described
by Andrews.5 Then, the axial inclination of the crown
was recorded by contacting the vertical rod with the
crown surface and reading the degree displayed by the
conveyor (Fig 1, A and B).
For measuring the inclinations of the canines, pre-
molars, and first molars, the posterior occlusal plane
was used as described by Ross et al,18 and the axial incli-
nation of teeth was measured as described for the ante-
rior teeth. Because of the TIP's structure, using the
occlusal plane, including the contact points with all in-
cisors, was not possible in all cases when measuring the
inclinations of the canines, premolars, and molars (Fig 1,
C and D).
For the 3D measurements, all casts were digitized
by the 3D scanner, and their 3D models were saved in
stereolithography format.
A simulator software program for 3D measurement
was developed at the Orthodontic Department of Shahid
Beheshti Dental School in Iran by 1 of the authors
(A.H.A.), a dentist who also has a master's degree in com-
puter science (artificial intelligence). This software has
the following capabilities: display of 3D point clouds,
triangulation of the point cloud and production of the
object's surface, measurement of distances between
points in a virtual model, definition of occlusal and
sagittal planes, measurement of the inclination of each
tooth, and superimposition of 2 dental models based
October 2014  Vol 146  Issue 4
524 Nouri et al

Fig 1. Measuring the inclination of the teeth with the TIP: A, anterior tooth inclination measurement,
frontal view; B, anterior tooth inclination measurement, occlusal view; C, premolar inclination measure-
ment, lateral view; D, premolar inclination measurement, occlusal view.

on the marked reference points. The software was devel-
oped using the C.Net format (Fig 2, A).
To determine the horizontal reference plane, the cast
file was opened in the software, and the occlusal plane
was drawn according to the method of Sjogren et al,14
using the incisal edge of a central incisor and the mesio-
buccal cusp tips of the maxillary first molars (3 points),
and the incisal edge of a central incisor and the mesio-
buccal cusp tips of the mandibular second molars (3
points) (Fig 2, B).
In the next phase, the respective tooth was selected,
and its facial axis point was marked automatically as the
midpoint between 2 points: the midpoint of the buccal
side of the occlusal table or incisal edge, and the deepest
point on the cementoenamel junction. Then the software
drew a tangent line to the facial axis point using these
data and reported its angle relative to the occlusal plane
as the inclination value. This was performed separately
for all teeth in all dental casts (Fig 2, C and D).
Because the reading accuracy of the 2 devices was
not similar, the measurements made by the 3D method
were rounded to 1 to be comparable with the TIP
method. To assess the correlation between the 2
methods, the torque measured by the TIP was compared
with the corresponding value measured by the software
with intraclass correlation coefficients (ICCs). Also, the
differences between measurements were calculated us-
ing the Dahlberg21 index. For assessing reliability, the
measurements in each method were repeated twice on
15 casts with a 1-week interval, and the ICC and the
Dahlberg index were calculated. The null hypothesis of
the study was that no significant correlation exists be-
tween measurements made with the TIP and the com-
puter software. Thus, P \0.05 indicated no significant
difference between the 2 measurement techniques.
RESULTS
We determined the correlations of the 2 methods and
the differences between them. Table I indicates the mean
torque for the maxillary teeth measured by the 2
methods, its standard deviations, results of the F test,
the P values, the ICC, and the Dahlberg21 index when
comparing the methods. The same data for the mandib-
ular teeth are shown in Table II. In the maxilla, the 2
methods had acceptable correlations (P \0.05) for all

October 2014  Vol 146  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Nouri et al 525

Fig 2. The programmed software in the Shahid Beheshti University orthodontic department: A, general
view of the software; B, selecting the horizontal reference plane; C, 3 points were selected: facial axis
point, its corresponding points on the occlusal or incisal surface and the cervical surface; D, the soft-
ware obtained the tangent line at the facial axis point using the reference points and reported its angle
relative to the occlusal plane as the inclination value.

Table I. Mean torque values (degrees) for the maxillary teeth measured by the TIP and the 3D software
Maxillary right Maxillary left

Tooth 6 5 4 3 2 1 1 2 3 4 5 6
3D
Mean 10.5 10.9 7.5 4.8 10.6 10.5 8.6 8.2 5.9 8.8 12.9 9.8
SD 4.8 6.4 7.6 7.4 5.7 6.1 4.4 7.6 5.7 8.5 7.6 3.5
TIP
Mean 11.1 13.7 11.8 5.4 8.2 7.1 6.7 4.4 6.6 12.4 14.1 10.9
SD 6.7 5.1 4.2 5.7 4.1 6.2 6.0 5.9 4.7 5.7 7.3 6.3
F 3.547 5.376 2.320 5.692 3.049 3.900 5.548 2.227 3.141 2.973 4.446 3.501
P value 0.006 0.001 0.046 0.000 0.014 0.004 0.000 0.054 0.012 0.015 0.002 0.007
ICC (r) 0.727 0.771 0.492 0.830 0.636 0.689 0.796 0.507 0.690 0.622 0.779 0.721
Dahlberg 3.8 3.7 5.6 3.5 3.8 4.5 3.1 5.8 3.6 5.6 4.5 4.5
P values less than 0.05 indicate no statistical significance considering the null hypothesis of negative correlation between the 2 methods.
6, First molar; 5, second premolar; 4, fist premolar; 3, canine; 2, lateral incisor; 1, central incisor.

teeth. Also, according to the Dahlberg index, the differ-
ences in measurements ranged from 3.1 (left central
incisor) to 5.8 (left lateral incisor).
In the mandible, the 2 methods had acceptable corre-
lations for all teeth (P \0.05). Furthermore, the differ-
ences in measurements according to the Dahlberg21
index ranged from 3.3 (left central incisor) to 5.9
(left lateral incisor).
Overall, the differences in measurements between the
2 methods were insignificant. The total correlation coeffi-
cient between the TIP and the software was 0.91, and the
total numeric difference in measurements was 4.4 .
For reliability, the ICC values were 0.73 and 0.82 for
repeated measurements made by the TIP and the soft-
ware on the 15 casts, respectively.
The Dahlberg21 index values for repeated measure-
ments made by the TIP and the software on the 15 casts
were 1.5 to 4 and 1.2 to 3.6 , respectively. The details
regarding the ICC and the Dahlberg index for the TIP and
the 3D software are given in Tables III and IV.
DISCUSSION
In this study, the buccolingual inclinations of inci-
sors, canines, premolars, and first molars in 36 dental

American Journal of Orthodontics and Dentofacial Orthopedics October 2014  Vol 146  Issue 4
526 Nouri et al

Table II. Mean torque values (degrees) for the mandibular teeth measured by the 2 methods
Mandibular right Mandibular left

Tooth 6 5 4 3 2 1 1 2 3 4 5 6
3D
Mean 36.1 25.4 18.2 10.3 1.8 7.9 6.4 3.6 9.2 21 27.4 32.9
SD 4.9 7.5 6.9 6.0 8.0 8.0 7.7 7.8 7.7 6.4 8.9 5.8
TIP
Mean 35.3 24.9 20.3 11.5 0.7 3.9 3.2 0.2 11.3 23.1 28.2 33.4
SD 5.8 6.5 6.0 6.9 5.7 6.2 6.7 6.3 7.7 8.9 7.1 6.1
F 5.585 2.633 2.045 6.739 5.971 10.405 4.035 7.934 8.754 2.470 6.031 3.603
P value 0.001 0.027 0.075 0.000 0.000 0.000 0.003 0.000 0.000 0.035 0.000 0.009
ICC (r) 0.757 0.633 0.505 0.850 0.835 0.843 0.719 0.827 0.873 0.593 0.839 0.734
Dahlberg 3.6 5.1 5.3 3.3 3.7 4.1 4.9 4 3.7 5.9 4.2 3.8
P values less than 0.05 indicate no statistical significance considering the null hypothesis of negative correlation between the 2 methods.
6, First molar; 5, second premolar; 4, fist premolar; 3, canine; 2, lateral incisor; 1, central incisor.

Table III. ICC values and the Dahlberg index for the TIP method in the 2 time measurements
Tooth

6 5 4 3 2 1 1 2 3 4 5 6
ICC 0.91 0.78 0.8 0.63 0.71 0.71 0.74 0.7 0.39 0.71 0.83 0.96
Dahlberg 4 1.9 1.9 2.6 2.2 3 2.1 3.4 2.8 2.5 1.5 2.6
These values indicate the reproducibility of the measurements.
6, First molar; 5, second premolar; 4, fist premolar; 3, canine; 2, lateral incisor; 1, central incisor.

Table IV. ICC values and the Dahlberg index for the 3D software in the 2 time measurements
Tooth

6 5 4 3 2 1 1 2 3 4 5 6
ICC 0.6 0.86 0.89 0.9 0.92 0.95 0.96 0.72 0.85 0.91 0.68 0.64
Dahlberg 3.6 2.4 3.1 2.7 1.2 1.6 2.1 2.2 2.4 3 1.9 2.9
These values indicate the reproducibility of the measurements.
6, First molar; 5, second premolar; 4, fist premolar; 3, canine; 2, lateral incisor; 1, central incisor.

casts of normal Class I occlusions were determined by a
manual technique with the TIP and a 3D method using a
newly developed software after scanning with a
structured-light 3D scanner with 10-mm precision. The
correlations between the 2 techniques and the reliability
of each method were evaluated.
The coronal landmarks used in the 2 methods were
equal, and the facial axis points were used for this pur-
pose. However, the horizontal reference planes were
different. In the TIP method, an occlusal plane tangent
to the molars and incisors was constructed for the inci-
sors. Nevertheless, use of this plane was difficult because
of the small horizontal plane of the device. When we re-
corded the inclinations of posterior teeth (canines, pre-
molars, and first molars), contact was not possible with
all incisors. Thus, the posterior occlusal plane was used
for these teeth.18 In the 3D measurement software, a
plane similar to that suggested by Andrews5,17 and
applied by Sjogren et al14 was used. It is obvious that
the difference in the horizontal reference planes causes
a systematic difference between the recorded inclina-
tions of the 2 methods. However, it seems that the over-
all effect of this issue is small and not great enough to
cause statistically significant differences between the 2
methods.
The numeric differences for the incisors (with the
same horizontal reference plane in both techniques)
and the posterior teeth (with different horizontal refer-
ence planes in the 2 methods) were not significant either
(the Dahlberg21 index ranged between 3.1 and 5.8 for
the maxillary incisors and between 3.5 and 5.6 for all
other posterior maxillary teeth). These ranges were 3.7
to 4.9 for the mandibular incisors and 3.3 to 5.9 for
all other posterior mandibular teeth. However, this

October 2014  Vol 146  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Nouri et al
finding does not indicate the clinical insignificance of
the horizontal reference plane for the measurement ac-
curacy of the inclination of tooth crowns. A fixed hori-
zontal reference plane is important, especially for the
measurement of alterations in tooth inclinations after
orthodontic treatment.10 Costalos et al9 evaluated the
correlations between the OrthoCad and the manual
technique in the measurements of the American Board
of Orthodontics' objective grading system criteria. They
observed a statistically significant difference when
measuring alignment and buccolingual inclination of
the teeth between the plaster and digital models. More-
over, in a similar study, Okunami et al13 excluded the
buccolingual inclination of the teeth from the compari-
son of the 2 methods because they believed that Ortho-
Cad was not capable of measuring this index according
to American Board of Orthodontics' criteria. This issue is
probably due to the different methods of assessment of
the buccolingual inclination relative to a horizontal line
passing through the corresponding cusp tip. Thus, when
recording the buccolingual inclination in the manual
and 3D methods, using a reference plane instead of
the line connecting the corresponding cusp tips in-
creases the similarity of the 2 techniques. Furthermore,
Kodaka et al12 compared the inclination of tooth crowns
according to the method of Andrews,5,17 using a 3D laser
scanner and Octane (Silicon Graphics) software with the
manual technique and a conveyor in their study. They
found no significant difference in the mean value of
the 2 methods; however, the variance of the 3D
method was higher than the manual technique.
For assessing the reliability of the TIP device in our
study, the measurements were repeated twice on 15
casts with a 1-week interval. The lowest ICC value be-
longed to a canine (0.39). This finding is probably attrib-
utable to the labial surface morphology and the large
angle at the incisal and cervical thirds of this surface
relative to the facial axis point. Furthermore, the level
of the canine tip, which is the highest relative to the
occlusal plane, causes fluctuations in the stability of
the occlusal plane when one is reading the inclinations
on the TIP. In this situation, we have fewer contact
points on the occlusal plane. The reliability for deter-
mining the inclination of incisors was 0.72, which is
close to the rate reported by Richmond et al (0.82).6
To the best of our knowledge, no data are available in
the literature regarding the accuracy of the TIP for
measuring the inclinations of canines, premolars, and
molars. However, the manual for this device claims
that it can be used for measuring the inclinations of pos-
terior teeth. Investigators should be aware of the differ-
ence between reference occlusal planes in measuring the
inclinations of incisors and canines or posterior teeth,
American Journal of Orthodontics and Dentofacial Orthopedics
527
because this device lacks contact with all anterior teeth
while measuring the inclinations of canines and poste-
rior teeth. In this study, the ICC for measuring the reli-
ability of the TIP for premolars and first molars ranged
between 0.71 and 0.96, and the Dahlberg21 index ranged
from 1.5 to 4 . These values were different from the
rates reported by Shu et al,22 who used a device similar
to the TIP with the posterior occlusal plane (the ICC
and the Dahlberg index in their study were 0.993 to
0.929 and 1.622 to 0.719 , respectively). However,
these differences were not clinically significant.
Overall, the reliability of the 3D method for anterior
teeth was higher than for posterior teeth (ICC values,
0.88, 0.76, and 0.87 for incisors, canines, and posterior
teeth, respectively). The ICC value between the 2 mea-
surements with this device was 0.82 for all teeth, and
the Dahlberg21 index ranged between 1.2 and 3.6 .
Thus, the reliability of the 3D method for measurement
of inclination was slightly better than the manual tech-
nique. This finding agrees with the results of Costalos
et al,9 who compared the OrthoCad and the conventional
technique for measurement of the American Board of
Orthodontics' objective grading system indexes. The reli-
ability of the 3D method used in our study was slightly
less than that of the 3D method used by Kodaka
et al12 (ICC, 0.98; Dahlberg index, 0.15 ). Moreover,
the lower reliability of the measurement of molar incli-
nation in our study agreed with the reports of by Se-
bata,23 Chiashi et al,8 and Kodaka et al.
In the literature, various techniques have been used
for the measurement of axial inclinations of teeth, and
variable landmarks have been used. Traditionally, lateral
cephalograms were used to measure the inclination of
the incisors. This technique provided the crown-root
inclination relative to a horizontal reference plane
(palatal, occlusal, or mandibular). However, the mistakes
in registering the landmarks to assess the inclination of
each tooth, or using the occlusal plane as the reference,
and the ionizing beam radiation are among the short-
comings of this technique.3,4,24,25 In dental cast-based
methods, some of these drawbacks have been obviated.
Andrews5,17 tried to determine the tooth crown
inclination, considering the facial axis of the clinical
crown and the occlusal plane that passes through the
anterior and posterior teeth. He used a glass sheet, a
conveyor, and a compass for this purpose and aimed
to determine the norm of tooth crown inclinations.
However, his technique was both time-consuming and
relatively difficult.
The TIP was first introduced for the measurement of
the inclination of incisors on a dental cast.6 Previous
studies have demonstrated that the TIP is a simple, inex-
pensive, and reliable tool for the assessment of tooth
October 2014  Vol 146  Issue 4
528
inclination.6,7 Such advantages were determining
factors for its use for measuring tooth inclinations on
dental casts in our study. However, it has some
inherent deficiencies regarding the validity of the
measurements, especially in the case of an inordinate
occlusal plane (eg, deep curve of Spee, severe curve of
Wilson, canted occlusal plane, malposed teeth, or
open-bite malocclusion).6,7 We used casts of normal
Class I occlusions because our main objective in this
study was to compare the 2 devices for their axial
inclination measurements capabilities. Richmond et al6
reported correlations of 0.77 and 0.59 for the inclina-
tions of the maxillary and mandibular incisors, respec-
tively, between their invented technique and lateral
cephalometry. Also, they showed that the TIP consis-
tently underestimated the maxillary incisor inclination
by 10.46 compared with lateral cephalometry, but it
overestimated the inclination of mandibular incisors.
In a similar study, Ghahferokhi et al7 demonstrated
that the TIP underestimated the inclination of incisor
crowns by an average of 14 relative to the maxillary
plane on lateral cephalometry. However, the TIP calcu-
lated the inclination of mandibular incisor crowns rela-
tive to the mandibular plane, similar to the value in
lateral cephalometry. In our study, the agreement index
values between our 2 methods were 0.657 and 0.806,
respectively, for measurement of the inclinations of the
maxillary and mandibular incisors. Moreover, the 3D
software overestimated the inclinations of maxillary
and mandibular teeth by 2.875 and 2.925 , respec-
tively. Although in this study the inclination of the inci-
sors in lateral cephalometry was not measured,
considering the differences between our study results
and those of Richmond et al, we can assume that the
3D software generally tends to report the inclination of
maxillary incisors closer and that of mandibular incisors
farther than the values measured on lateral cephalom-
etry compared with the TIP. Meanwhile, when interpret-
ing these results, it should be taken into account that the
horizontal reference plane used in the 3D method was
slightly different from the one used in the TIP.3,4,6,24
On the other hand, considering the popularity of
CBCT because of its lower costs and radiation doses,
it is now possible to accurately assess the crown and
root 3 dimensionally.15 Shewinvanakitkul et al16
measured the inclination of the mandibular canines
and the first molars using CBCT, with the mandibular
plane as the reference plane. The reliability of this tech-
nique was reported to be excellent (.0.94). In general,
in studies assessing tooth inclinations on the casts, the
occlusal plane was used, and in radiographic studies,
skeletal planes have been used. Considering the change
of occlusal plane during orthodontic treatment, this
October 2014  Vol 146  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Nouri et al
plane does not have enough stability to be used as a
reference plane for measuring tooth inclination.
Furthermore, use of radiographic techniques such as
CBCT has 2 drawbacks: exposure to the ionizing beam
and feasibility of application.
Overall, since the standard deviations of the measure-
ments for all teeth were greater than the differences be-
tween the measurements made with the 2 methods and,
also, greater than the reliability of each technique alone,
it seems that both the TIP and the 3D software have clin-
ically acceptable accuracy for measuring the inclinations
of teeth.
CONCLUSIONS
A high correlation (r 5 0.91) was found between the
TIP device and our 3D method for crown inclination
measurements. The overall difference between the 2
methods was 4.4 . The reliability of measurements in
the 3D method was higher than that with the TIP device
(ICC values, 0.82 vs 0.73, respectively).
ACKNOWLEDGMENT
We thank all the persons who collaborated in this
study for their scientific and financial support.
REFERENCES
1. Andrews LF. The six keys to normal occlusion. Am J Orthod 1972;
62:296-309.
2. Andrews LF. The straight-wire appliance, origin, controversy, com-
mentary. J Clin Orthod 1976;10:99-114.
3. Baumrind S, Frantz RC. The reliability of head film measurements:
1. Landmark identification. Am J Orthod 1971;60:111-27.
4. Baumrind S, Frantz RC. The reliability of head film measurements:
2. Conventional angular and linear measures. Am J Orthod 1971;
60:505-17.
5. Andrews LF. Straight wire: the concept and appliance. San Diego:
LA Wells; 1989.
6. Richmond S, Klufas ML, Sywanyk M. Assessing incisor inclination:
a non-invasive technique. Eur J Orthod 1998;20:721-6.
7. Ghahferokhi AE, Elias L, Jonsson S, Rolfe B, Richmond S. Critical
assessment of a device to measure incisor crown inclination. Am
J Orthod Dentofacial Orthop 2002;121:185-91.
8. Chiashi M, Aria K, Nakahara R. Measurement method of three-
dimensional crown inclination—the effect of differences in bracket
base area on the analysis of crown inclination. Orthod Waves 2004;
63:186-92.
9. Costalos PA, Sarraf K, Cangialosi TJ, Efstratiadis S. Evaluation of
the accuracy of digital model analysis for the American Board of
Orthodontics objective grading system for dental casts. Am J Or-
thod Dentofacial Orthop 2005;128:624-9.
10. Ferrario VF, Sforza C, Colombo A, Ciusa V, Serrao G. Three-
dimensional inclination of the dental axes in healthy permanent
dentitions—a cross-sectional study in a normal population. Angle
Orthod 2001;71:257-64.
11. Fukagawa H, Motegi E, Fuma A, Nomura M, Kano M, Sueishi K,
et al. Tooth inclination in elderly with many remaining teeth
observed by 3-D imaging. Bull Tokyo Dent Coll 2010;51:69-76.
Nouri et al
12. Kodaka K, Nishii Y, Sakurai Y, Nojima K, Sueishi K. Crown inclina-
tion measured by laser scanner. Orthod Waves 2010;69:8-12.
13. Okunami TR, Kusnoto B, BeGole E, Evans CA, Sadowsky C,
Fadavi S. Assessing the American Board of Orthodontics objective
grading system: digital vs plaster dental casts. Am J Orthod Den-
tofacial Orthop 2007;131:51-6.
14. Sjogren AP, Lindgren JE, Huggare JA. Orthodontic study cast anal-
ysis—reproducibility of recordings and agreement between con-
ventional and 3D virtual measurements. J Digit Imaging 2010;
23:482-92.
15. German DS, German J. Cone-beam volumetric imaging: a two-
minute drill. J Clin Orthod 2010;44:253-65.
16. Shewinvanakitkul W, Hans MG, Narendran S, Palomo JM.
Measuring buccolingual inclination of mandibular canines and
first molars using CBCT. Orthod Craniofac Res 2011;14:168-74.
17. Andrews LF. Straight wire. Basi teoriche e applicazioni pratiche.
Milan, Italy: Elsevier Masson; 1993.
18. Ross VA, Isaacson RJ, Germane N, Rubenstein LK. Influence of
vertical growth pattern on faciolingual inclinations and treat-
American Journal of Orthodontics and Dentofacial Orthopedics
529
ment mechanics. Am J Orthod Dentofacial Orthop 1990;98:
422-9.
19. Marcel TJ. Three-dimensional on-screen virtual models. Am J Or-
thod Dentofacial Orthop 2001;119:666-8.
20. Favero L, Terrazzani C, Favero V, Stellini E, Cocilovo F. Virtual
study models: a comparison of modular application systems.
Prog Orthod 2009;10:16-25.
21. Dahlberg G. Statistical methods for medical and biological stu-
dents. New York: Interscience Publications; 1940.
22. Shu R, Han X, Wang Y, Xu H, Ai D, Wang L, et al. Comparison of
arch width, alveolar width and buccolingual inclination of teeth
between Class II division 1 malocclusion and Class I occlusion.
Angle Orthod 2013;83:246-52.
23. Sebata E. An orthodontic study of teeth and dental arch form on
the Japanese normal occlusions. Shikwa Gakuho 1980;80:945-69.
24. Houston W. The analysis of errors in orthodontic measurements.
Am J Orthod 1983;83:382-90.
25. Wall B, Kendall G. Collective doses and risks from dental radiology
in Great Britain. Br J Radiol 1983;56:511-6.
October 2014  Vol 146  Issue 4