Received: 31 July 2018 Accepted: 5 September 2018

DOI: 10.1111/jerd.12426

RESEARCH ARTICLE

Diagnostic accuracy of intraoral photographic orthodontic

records
Tate H. Jackson DDS, MS1 | Christopher J. Kirk DDS, MS, FRCD(C)2 |
Ceib Phillips MPH, PhD1 | Lorne D. Koroluk DMD, MSD, MS1,3

1
Department of Orthodontics, UNC School of
Dentistry, Chapel Hill, North Carolina
2
Private Practice of Orthodontics, Ontario,
Canada
3
Department of Pediatric Dentistry, UNC
School of Dentistry, Chapel Hill, North
Carolina
Correspondence
Tate H. Jackson, DDS, MS, Department of
Orthodontics, UNC School of Dentistry,
273 Brauer Hall, Campus Box 7450, Chapel
Hill, NC 27599-7450.
Email: tatejackson@unc.edu
Funding information
Foundation of the American Association of
Orthodontists, Grant/Award Number:
Orthodontic Faculty Development Fellowship
Award
Abstract
Objective: The aims of this study were (1) to investigate how relevant intraoral photographs are
to contemporary orthodontic diagnosis and (2) to assess orthodontists' ability to accurately diag-
nose angle classification and dental midlines using standardized intraoral photographs.
Methods: Study participants were orthodontists who completed a survey regarding photogra-
phy protocols and their use of intraoral photographs for diagnosis. Each participant was random-
ized to complete 1 visual diagnostic task regarding either angle classification or midlines.
Accuracy was compared across groups and camera angulations.
Results: In all, 80% of 192 respondents reported using photographs and clinic notes to plan
orthodontic treatment; 50% also included dental casts. For the angle task, accuracy judging
molar and canine classification was 79.9% and 51.3%, respectively with ideal standardized pho-
tographs. As camera angulation deviated, accuracy decreased significantly (P < 0.0001). For the
midline task, accuracy judging the direction of deviation decreased with a small camera angula-
tion change yet increased with a large change (P < 0.001).
Conclusions: When using ideal intraoral photographs alone to diagnose angle classification and
midline relationships, accuracy is not likely to be greater than 80%. As camera angulation
becomes less ideal, by 15 degrees when judging angle classification or 4 degrees when judging
midlines, accuracy is likely to significantly decrease.

Clinical significance
For the clinician who wants to have the most accurate and complete records, our results suggest
that intra-oral photos alone may not be adequate when it comes to judging occlusal relation-
ships such as angle classification and esthetic parameters like midlines. When using ideal
intraoral photographs to diagnose angle classification and midline relationships, accuracy is not
likely to be greater than 80%. As camera angulation becomes less ideal, by as little as 15 degrees
when judging angle classification or 4 degrees when judging midlines, accuracy is likely to
decrease significantly. Understanding these limitations will allow clinicians to improve both their
clinical photography technique and their diagnostic skills.

KEYWORDS

clinical photography, dental midlines, diagnosis, orthodontics

1 | I N T RO D UC T I O N
Accurate photographic documentation in orthodontics is key both for
medicolegal record-keeping and to aid the clinician in the diagnosis
and treatment planning process. The connection between orthodon-
tics and clinical photography is longstanding and reaches back more
than 150 years. A dentist from New York city was responsible for
opening the first commercial photographic studio in 1840,1 and
Edward angle is recognized as the first orthodontist to routinely use
photography for diagnosis.1 In 1979, Goodlin created a standardized
guide for various intraoral photography views, magnification ratios,
and procedures in an attempt to improve treatment outcomes.2

64 © 2018 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2019;31:64–71.

JACKSON ET AL.
In the United States, the American Association of Orthodontists
(AAO) does not currently have a national standard of care for ortho-
dontic records but has left it to the State Dental Boards to establish
the standard of care.3 Although specific required orthodontic records
are not outlined, the AAO states that the records must be “sufficient”
to identify problems, accurately establish a diagnosis, and formulate a
treatment plan.3 One current professionally established standard for
intraoral photographic records is outlined by the American Board of
Orthodontics. It includes right and left buccal photographs, occlusal,
and frontal views with the teeth in maximum intercuspation (MI).4 This
standard is widely accepted as the general guideline for intraoral pho-
5–7
tography in the United States and in some areas outside the US.
Recent advances in imaging techniques, including CBCT and digi-
tal intra-oral surface scans of the teeth,8 have created new means for
recording information that intraoral photographs have historically cap-
tured. New treatment methods, including teledentistry techniques,
rely increasingly on photographs, video-based interaction, and other
records for diagnosis, rather than in-person examinations.9–11
In the current practice environment where practical technology
exists that might replace intraoral photography, how relevant are
photos to orthodontic diagnosis and record-keeping? Importantly,
how accurate is the diagnostic process using current standard of care
intraoral photographs? To address these questions, the authors under-
took an investigation combining a clinical survey with a test of visual
diagnostic skill across 2300 orthodontists actively practicing in the US
and around the world.
More specifically, this study aimed to: (1) evaluate the contempo-
rary reported use of intraoral photographs for diagnosis in clinical
orthodontic practice, (2) evaluate the diagnostic ability of practicing
orthodontists to judge angle classification and midline relationships
using standardized intraoral photographs, and (3) evaluate the influ-
ence of camera perspective on the ability of practicing orthodontists
to accurately judge angle classification and midline relationships using
standardized intraoral photographs.
2 | MATERIALS AND METHODS
2.1 | Participants
This study was approved by the Institutional Review Board at the Uni-
versity of North Carolina at Chapel Hill, IRB #15-0307. Study partici-
pants were composed of actively practicing orthodontists who were
members of the AAO at the time of the study. Though the AAO Part-
ners in Research Program, 12
an email with a link to the combined sur-
vey and tasks, and with a brief explanation of the study's aims and
request to participate, was sent to the 2300 active members who had
agreed to receive such messages. Two weeks after the initial email, a
follow-up message was sent. Orthodontic residents and retired practi-
tioners were excluded from the survey.
2.2 | Survey construction
The electronic survey questionnaire was constructed using Qualtrics
research software (Qualtrics Research Suite, Provo, UT). Demographic
65
data, including age, sex, and ethnicity, were reported by all partici-
pants. Participants were also asked to report their practice location,
number of years of practice, and practice hours per week, as well as
information regarding photographic protocols and armamentarium
used in their practice (including the frequency of photographs taken
before, during, and after treatment). Importantly, participants were
asked to report both the use of photographs for diagnosis relative to
other records (eg, casts) and to assign relative importance to each of
the records used in diagnosis. To minimize participant participation or
motivation bias, these survey questions were recorded after the par-
ticipant had completed the diagnostic tasks described below.
2.3 | Standardized photograph construction and
diagnostic tasks
To generate standardized diagnostic photographs to use as visual
stimuli, the pretreatment diagnostic casts of consecutive patients trea-
ted at the University of North Carolina at Chapel Hill Graduate Ortho-
dontic Clinic between August and December of 2013 were examined,
and 12 sets of casts were selected that met the following inclusion cri-
teria: adult dentition, buccal segments fully erupted (excluding second
and third molars), Class I or Class II molar and canine occlusion, posi-
tive buccal and anterior overjet and overbite, with both the maxillary
and mandibular midlines visible in MI. Casts were excluded if the sub-
ject had missing teeth other than third molars, erupted supernumerary
teeth, any crossbites, Class III occlusion, or an openbite at any point
across the arches at MI.
The maxillary and mandibular dental casts were articulated using
a wax occlusal record of MI and marked with a scoring tool to facili-
tate exact rearticulation throughout the study. The articulated casts
were evaluated by 3 independent board-certified orthodontists to
determine both the dental midline discrepancy and angle classification
(molar and canine) to be used as a “Gold” standard. The assessment
was repeated 1 week later and any discrepancies among examiners
were settled by consensus.
Each set of articulated casts was photographed from both the
frontal and buccal aspect to create a frontal view image and a buccal
view image, respectively. Standardized variations in camera angulation
were used to simulate actual clinical conditions where photos may be
taken at less than ideal angulation.5,13 To standardize the photographs
at the specified angles, an apparatus was constructed to orient the
camera and models in an accurate and reproducible position. A rotat-
ing plinth was constructed as the platform on which the dental casts
were photographed (see Figure 1A). Specific angulations as well as the
center of rotation were marked on the surface of the plinth, which
allowed for precise rotation in the axial plane. The camera (Canon T3i
DSLR, Canon MR-14EX ring flash and Canon EF 100 mm f/2.8 IS
USM) was mounted on a tripod with the center of the lens (point of
focus) leveled with the vertical height of the occlusal plane. The dis-
tance from the lens to the center of rotation was standardized and
measured at 310 mm for all photographs. The photos were exposed
at ISO 200, 100 mm, 0 ev, f/32, 1/200 and saved as a JPEG file.
For the buccal view photographs (used for the angle classification
task), the casts were positioned on the plinth such that the center of
rotation of the plinth coincided with the midpoint on a tangent from
66
FIGURE 1 A, Rotating plinth for standardized photographs; B, Example of a diagnostic accuracy question presented using Qualtrics software; C,
Example of an image used for the midline task; D, Example of an image used for the angle task
the cusp tip of the mandibular canine to distobuccal cusp of the man-
dibular first molar. The buccal view photographs were repeated in
3 axial inclinations relative to a tangent of right-side buccal segment:
zero deviation (perpendicular to the buccal segment, considered
“ideal” angulation; 15 degrees of deviation anterior to the buccal seg-
ment tangent; and 30 degrees of deviation anterior to the buccal seg-
ment tangent). An asterisk was superimposed over the canines and
first molars in each buccal photograph using graphic design software
(Affinity Designer, Serif Europe Limited, Nottingham, UK) to draw
attention to the teeth that would be used to determine angle classifi-
cation using these images (see Figure 1D).
For the frontal view photographs (used for the midline task), the
casts were positioned on the plinth such that the center of rotation of
the plinth coincided with the incisal contact point of the mandibular
central incisors. The midsagittal midline was determined by a line
intersecting the midpoint of the transverse width from the mesiobuc-
cal cusps of the mandibular first molars and the embrasure of the
mandibular central incisors. The occlusal plane was leveled with the
plinth surface using a fox plane. The frontal view photographs were
taken at 3 different angulations to the midline: zero degrees to mid-
sagittal (considered “ideal” angulation), 4degrees left of midsagittal,
and 8 degrees left of midsagittal. One calibration photograph was
exposed that included a millimeter ruler in the frame. The raw image
files were imported into the graphic design software, and using the
calibration photograph, a digital 5 mm ruler with 1 mm increments
was superimposed on the photograph over the left lateral and central
incisor, close to the midline (see Figure 1C).
All diagnostic tasks were completed by participants using the
same Qualtrics Survey platform used for the survey described above
(see Figure 1B). Participants were randomly assigned by the Qualtrics
software to one of 2 independent blocks of questions: the angle clas-
sification task block or midline task block. Both question blocks con-
sisted of 36 unique images with 4 replicates to establish intra-rater
reliability. The order of images presented in both blocks was random-
ized using a random number generator, with the condition that identi-
cal images were not shown consecutively. For the angle classification
JACKSON ET AL.
block, participants were asked to view images of the buccal occlusion
and determine both the molar and canine angle classification in ¼ cusp
increments. For the midline task block, participants were asked to
view frontal images of the occlusion and to rate both the degree of
dental midline discrepancy and the direction of the maxillary dental
midline discrepancy (coincident or to the right or left of the mandibu-
lar dental midline). The degree of midline discrepancy was recorded in
0.5 mm increments from 0 mm to 5 mm.
2.4 | Statistical analysis
Descriptive statistics were reported for participant demographics,
practice location and experience, practitioner-reported photographic
practices, and the reported use and importance of photographic
records in diagnosis. Reliability measures for the diagnostic ability
tasks within participant were calculated as intra-rater reliability using
the Kappa statistic and extended McNemar analysis. Accuracy was
reported as percent of responses correct for both angle classification
and midline tasks and compared across stimuli condition (degree of
deviation from ideal) within each task using Chi-square and condi-
tional logistic regression. Level of significance was set at P ≤ 0.05.
Statistical analysis was performed using SAS v 9.3 (Cary, NC).
3 | RE SU LT S
The survey was distributed to 2300 members of the AAO. A total of
192 participants consented to participate and completed the survey,
resulting in an 8.3% response rate. One hundred and sixty eight of
these participants additionally completed the diagnostic task block to
which he or she was assigned: 96 completed the angle classification
task; 72 completed the midline task. 94.3% of participants were from
the United States whereas the remainder was AAO members from
other areas of the world. The United States was further sub-divided
into regions: northeast, midwest, south, and west (see Table 1), with
the majority of subjects from the south and the fewest from the
northeast. The majority of participants were male (87.2%). The
JACKSON ET AL. 67

TABLE 1 Participant characteristics by region, age, and gender

Region N = 192
Northeast (%) Midwest (%) South (%) West (%) Non US (%) Total (%)
10.9 19.3 40.6 23.4 5.7
Age in years
28-39 0.5 4.7 11.0 6.8 3.1 26.2
40-55 2.1 2.1 10.5 7.3 1.1 23.0
56-65 4.2 8.3 10.0 4.2 1.1 27.8
66+ 4.2 4.2 8.9 5.2 0.5 23.0
Gender
Male 8.9 17.2 35.9 21.3 4.17 87.5
Female 2.1 2.1 4.7 2.1 1.1 12.5

majority of participants (82.0%) identified themselves as Caucasian.
Median participant age was 54 years (IQR = 39-66), with a median of
25 years (IQR = 7-35) experience in practice and a current median of
32 hours (IQR = 28-36) of practice per week (see Table 1).
77% of participants reported capturing intraoral photographs only
for initial diagnosis and as a final post-treatment record. Only 2%
reported capturing photographs at every patient appointment (see
Table 2). Out of which 15% of participants reported that the ortho-
dontist alone captures photographs, and the majority reported that
members of the auxiliary team are primarily responsible for acquiring
test, indicating a consistent or systematic shift in response from the
first exposure to the second exposure to the same question.
Participant accuracy for the angle classification task may be found
in Table 3. Ninety-six participants were randomly assigned to com-
plete the angle classification task, resulting in 3840 observations from
which to evaluate the diagnostic ability of practicing orthodontists.
With a photograph at an ideal angulation, participants were 79.9%
and 51.3% accurate in judging molar and canines classification,
respectively. As deviation of camera perspective increased, accuracy
decreased. A statistically significant difference in accuracy across age

intraoral photographs (see Table 2). More than 67% of respondents groups was found in judging canine classification only (P = 0.05). Con-

use a digital single-lens reflex camera, and only 31% reported using a ditional logistic regression was used to control for the potential influ-

mirror to acquire buccal occlusion views. ence of age, gender, and region on accuracy of judgment. Statistically

When asked what records each participant obtained and used pri- significant decreases in the odds of accurately assessing both molar

marily to plan orthodontic treatment, clinical notes and photographs and canine angle classification were found as deviation in camera per-
spective increased (see Table 4).
were each selected by nearly 80% of respondents, whereas just more
Accuracy for the midline Task may be found in Table 5. Seventy-
than 50% also included dental casts (see Figure 2). When asked to
two participants were randomly assigned to the midline task block,
rank the relative importance of each type of record, clinical notes
resulting in 2880 observations. At an ideal camera angulation, partici-
were rated as “Most Important”, followed by intraoral photographs,
pants accurately indicated the direction of midline deviation (right, left
and then by dental casts (see Figure 3).
or coincident) 76.98% of the time, and were only 44.39% accurate in
Reliability of both the angle classification and midline tasks was
judging the degree of discrepancy in 0.5 mm increments of deviation.
assessed using a 10% subset of replicated questions answered twice
Only participant practice location had a statistically significant influ-
by each participant. All of the repeated questions were considered,
ence on accuracy of judging the direction of midline deviation
using the kappa statistic, to have “fair” strength of agreement or bet-
(P = 0.05). As camera perspective deviated, accuracy decreased in
ter (κ > 0.20), and 63% had moderate or better agreement
terms of judging the degree of midline discrepancy. Interestingly,
(κ > 0.40).14 Only 3 questions demonstrated statistically significant
accuracy in judging the direction of deviation decreased with a small
discordance (P ≤ 0.05) when assessed using an extended McNemar

TABLE 2 Reported photographer and frequency of intraoral

photographs
Frequency of photographic records N = 192 (%)
Initial and final 77.07
One series mid-treatment 13.17
2–5 series mid-treatment 17.07
Every appointment 1.95
Photographer
Dental assistant 38.30
Orthodontist only 14.60
Other 32.5
FIGURE 2 % Responses indicating that the participant obtained and
No response 13.60
primarily used certain records for orthodontic treatment planning
68 JACKSON ET AL.

United States. As all participants were active members of the AAO

and participants in the Partners in Research Program, the results
obtained represent the cross-sectional perspective of orthodontists
who are willing members of a professional organization. Not surpris-
ingly in this group, intraoral photographic records were a part of all
participants' baseline diagnostic records. Interestingly, only 77%
reported obtaining both initial and final photographic records, and less
than 2% reported obtaining photos at each patient visit. These results
certainly suggest that initial diagnostic intraoral photographs are a
nearly universal part of orthodontic treatment.
When asked to rate the relative importance of intraoral photo-
graphs, clinic notes, and dental casts to treatment planning, partici-
pants ranked photographs second in importance behind clinic notes
FIGURE 3 % Responses indicating the relative level of importance of
(see Figure 3). Dental casts were considered of less importance than
each record for orthodontic treatment planning
photographs. Similarly, study participants indicated that they obtained

change in camera perspective but increased as the perspective and used clinic notes and photographs almost equally when asked

became more skewed. Even when controlling for participant age, gen- what records were used primarily for treatment planning. Dental casts

der, and location, conditional logistic regression revealed that as cam- were obtained and used less often (see Figure 2). Together, these

era perspective deviated from perpendicular, accuracy in assessing
the direction of midline discrepancy actually increased with the
degree of deviation. Using the same logistic model, accuracy
decreased with a more nonideal camera angulation when assessing
the degree of midline discrepancy (see Table 6).
4 | DISCUSSION
The 8.3% response rate generated from an electronic message and
single follow-up request resulted in a study sample that included at
least 20 participants from each geographic region of the United
States. Only 5% of respondents reported practicing outside of the
results further indicate that intraoral photographs are an important
resource in contemporary treatment planning—perhaps more impor-
tant than dental casts. It is possible that some respondents regularly
obtain and use digital models but did not indicate such using this sur-
vey tool. Nonetheless, photographs capture additional information
that is unique from dental casts alone, such as greater detail regarding
soft tissues, and so it is logical that photos might be ranked as more
important than casts. Even if one assumes that clinical inspection or
the use of dental casts are more ideal ways to assess angle classifica-
tion or dental midlines, these survey data suggest that it is pertinent
to know if photos can accurately be used for such judgments. For the
roughly half of respondents in this study who indicated that they did
not routinely obtain dental casts, then the only record of certain

TABLE 3 Angle classification task accuracy by degree of camera angulation from ideal, participant age, gender, and region

Molar angle classification Canine angle classification

accuracy accuracy
Camera angulation from ideal % Correct % Correct N = 168
(degrees)
0 79.86 51.29
15 62.61 47.92
30 48.16 P = <0.0001* 33.18 P = <0.0001*
Age (years)
28–39 66.45 48.69
40–55 61.65 40.88
56-66 61.67 42.22
66+ 64.13 42.63 P = 0.005*
Gender
Male 62.91 43.65
Female 66.32 P = 0.10 43.92 P = 0.90
Region
Northeast 65.74 42.75
Midwest 61.36 44.07
South 64.65 43.36
West 62.25 44.93
Non US 62.78 P = 0.39 43.33 P = 0.95

*P ≤ 0.05; Chi-square analysis.

JACKSON ET AL. 69

TABLE 4 Odds of a correct response for angle classification tasksa

Molar angle Canine angle

classification classification
Camera angulation from ideal 95% Confidence 95% Confidence
(degrees) Odds ratio interval Odds ratio interval
0 versus 15 3.21 (2.59-3.98) 1.23 (1.01-1.51)
0 versus 30 7.18 (5.58-8.97) 3.07 (2.50-3.78)
15 versus 30 2.24 (1.83-2.73) 2.49 (2.03-3.06)
a
Conditional logistic regression, controlling for participant age, gender, and region.

occlusal characteristics would be clinic notes and intraoral photo-
graphs. Consider the medicolegal situation in which casts are not
available, but records are needed to verify clinic notes. Is it sensible to
assume that a practicing orthodontist can accurately diagnose angle
classification or dental midline discrepancies from intraoral photo-
graphs alone?
For the angle classification task, when photos were taken from an
ideal camera angulation, accuracy was 79.86% judging molar classifi-
cation and 51.29% judging canine classification. These results suggest
that even with ideal photographs, in up to 20% of situations, ortho-
dontists might be inaccurate compared to using dental casts in hand.
The degree of inaccuracy ranged from ¼ to 3/4 cusp deviation from the
correct response. In up to 50% of cases, orthodontists might be inac-
curate judging canine relationships. As camera perspective changed,
deviating to simulate clinical situations in which ideal photographic
conditions are not possible, accuracy decreased to less than 50% for
molar classification and only 33% for canine classification (see
Table 3). Even when controlling for participant age, gender, and
regional location, orthodontists had 3 times the odds of a correct
response with an ideal camera angulation versus 15 degrees of devia-
tion, and 7 times the odds versus 30 degrees of deviation (see
Table 4). When controlling for the same factors, the odds of a correct
canine classification were decreased only slightly less by camera
perspective.
At an ideal camera angulation, participants made a correct assess-
ment of the direction of midline deviation 76.98% of the time but only
correctly identified the degree of deviation (in 0.5 mm increments)
44.39% of the time. As camera deviation increased, the accuracy of
judging the degree of discrepancy decreased to just below 30% (see
Table 5). The effect of a change in camera perspective on accuracy
assessing the direction of deviation was unexpected, however. With
4 degrees of deviation, accuracy dropped to 67.08% when judging the
direction of midline deviation, but with 8 degrees of camera angle
change, accuracy actually increased and approached accuracy with an
ideal camera angulation. Why would such counterintuitive results be
found?
As the camera perspective was skewed further from a direct per-
pendicular view, the evident difference in maxillary and mandibular
midlines was amplified. Here, a photographic equivalent of the buccal
object rule came into play. As the maxillary midline was closer to the
camera itself than the mandibular midline, when the camera moved to
the side, the apparent lateral distance between the midlines increased.
Just as the buccal object “moves” laterally in a radiograph when the
tube head is moved, so too did the maxillary midline “move.” With a

TABLE 5 Midline task accuracy by degree of camera angulation from ideal, participant age, gender, and region

Midline directiona accuracy Midline degreea accuracy

Camera angulation from ideal (degrees) % Correct % Correct
0 76.98 44.39
15 67.08 32.92
30 72.48 P = <0.0001b 27.10 P = <0.0001b
Age (years)
28–39 73.09 35.07
40–55 70.13 34.21
56–66 73.48 35.51
66+ 72.10 P = 0.48 36.27 P = 0.87
Gender
Male 72.08 35.54
Female 74.04 P = 0.52 30.64 P = 0.13
Region
Northeast 60.19 35.19
Midwest 74.44 34.44
South 73.04 36.27
West 73.16 34.43
Non US 74.45 P = 0.05b 37.96 P = 0.85
a
Midline direction was judged as the direction (right, left, or coincident) of deviation. Midline degree was judged in 0.5 mm increments of deviation.
b
P ≤ 0.05; Chi-square analysis.
70
TABLE 6 Odds of a correct response for midline tasksa
Midline directionb
Camera angulation from ideal (degrees) Odds ratio
0 versus 15 2.36
0 versus 30 1.59
15 versus 30 0.67
a
Conditional logistic regression, controlling for participant age, gender, and region.
b
Midline direction was judged as the direction (right, left, or coincident) of deviation. Midline degree was judged in 0.5 mm increments of deviation.
greater perceived difference in the lateral distance between the mid-
lines, a correct judgment of the direction of deviation would be more
likely. In this study, that effect was seen with 8 degrees of deviation,
but not at 4 degrees. When controlling for gender, age, and practice
location, the same patterns held (see Table 6).
Even under the most desirable clinical conditions and with the
most skilled technician, obtaining an ideal intraoral photograph may
be impossible. The results of this study suggest that the effect of a
nonideal camera angulation can significantly affect the ability to diag-
nose occlusal relationships. In the case of angle classification, the
result is predictable. When assessing midlines, small deviations in cam-
era perspective led to greater inaccuracy, whereas larger ones actually
diminished the negative effect. What is the clinical relevance of these
findings to the contemporary practicing orthodontist?
When considered together, the results of both the angle classifi-
cation and midline tasks support the common sense assumption that
as camera angulation becomes less ideal, diagnostic ability is
decreased. Perhaps, more clinical relevance is the fact that even in an
ideal situation, accuracy in judging occlusal relationships using
intraoral photographs might be capped near 80%. If one assumes that
using dental casts in hand would result in 100% accuracy, then the
significance of these results become clearer. It must be remarked,
however, that the data reported here represent not just accuracy, but
consistency as well, to some degree. Although the visual stimuli had
indicators directing each participant to only use the molars or canines
to make angle classification judgments and a millimeter ruler to make
midline judgments, it is possible that some respondents considered
premolar relationships or some other occlusal factors in making indi-
vidual assessments. If one accepts that angle classification includes
any degree of subjectivity, then the accuracy level using ideal images
also represents the degree to which orthodontists who completed the
tasks agree. Neither can the relative clinical significance level of such
accuracy be determined from the results here alone. The difference in
assessing a ½ cusp Class II occlusion versus a ¼ cusp Class II occlusion,
for example, may or may not be relevant to clinical success in some
cases. A very small deviation in dental midlines might be a problem for
some patients but not for others. Instead, the data presented here
indicate an upper boundary of accuracy and agreement when using
photographic records to assess occlusal relationships, which can serve
as a meaningful guide for clinicians seeking the highest quality and
completeness of orthodontic records.
Whether intraoral photographs are used for diagnosis or medico-
legal documentation, it is evident that the fidelity of these records has
limitations. It is also apparent from the results of this survey, that
intraoral photographs are a key part of modern practice. For the
JACKSON ET AL.
Midline degreeb
95% Confidence interval Odds ratio 95% Confidence interval
(1.76-3.16) 1.60 (1.32-1.94)
(1.18-2.13) 2.20 (1.80-2.68)
(0.51-0.90) 1.38 (1.12-1.69)
clinician who wants to have the most accurate and complete records,
our results suggest that intraoral photos alone may not be adequate
when it comes to judging occlusal relationships such as angle classifi-
cation and midlines. Given the increasing availability, speed, and ability
to capture color images, intraoral scanners might be a more accurate
supplement or alternative.15,16 Further research is warranted to
explore the use of intraoral scanners as an alternative to the tradi-
tional photograph and cast combination. Although three-dimensional
radiographic images might accurately capture occlusal relationships, it
is difficult to rationalize increased radiation exposure simply to do so.
5 | CONC LU SIONS
Intraoral photographs are an important record used for diagnosis in
the contemporary practice of orthodontics. When using ideal intraoral
photographs to diagnose angle classification and midline relationships,
accuracy is not likely to be greater than 80%. As camera angulation
becomes less ideal, by as little as 15 degrees when judging angle clas-
sification or 4 degrees when judging midlines, accuracy is likely to
decrease.
ACKNOWLEDGMENT
We thank the Foundation of the American Association of Orthodon-
tists for support via an Orthodontic Faculty Development Fellowship
Award.
DISC LOSURE
The authors do not have any financial interest in the companies
whose materials are included in this article.
ORCID
Tate H. Jackson https://orcid.org/0000-0002-5010-9253
RE FE RE NC ES
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How to cite this article: Jackson TH, Kirk CJ, Phillips C,
Koroluk LD. Diagnostic accuracy of intraoral photographic
orthodontic records. J Esthet Restor Dent. 2019;31:64–71.
https://doi.org/10.1111/jerd.12426
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