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ORIGINAL ARTICLE

Orthodontic soft-tissue parameters: A comparison of cone-beam computed tomography and the 3dMD imaging system
Tasha E. Metzger,a Katherine S. Kula,b George J. Eckert,c and Ahmed A. Ghoneimad Indianapolis, Ind, and Cairo, Egypt

Introduction: Orthodontists rely heavily on soft-tissue analysis to determine facial esthetics and treatment stability. The aim of this retrospective study was to determine the equivalence of soft-tissue measurements between the 3dMD imaging system (3dMD, Atlanta, Ga) and the segmented skin surface images derived from cone-beam computed tomography. Methods: Seventy preexisting 3dMD facial photographs and conebeam computed tomography scans taken within minutes of each other for the same subjects were registered in 3 dimensions and superimposed using Vultus (3dMD) software. After reliability studies, 28 soft-tissue measurements were recorded with both imaging modalities and compared to analyze their equivalence. Intraclass correlation coefcients and Bland-Altman plots were used to assess interexaminer and intraexaminer repeatability and agreement. Summary statistics were calculated for all measurements. To demonstrate equivalence of the 2 methods, the difference needed a 95% condence interval contained entirely within the equivalence limits dened by the repeatability results. Results: Statistically signicant differences were reported for the vermilion height, mouth width, total facial width, mouth symmetry, soft-tissue lip thickness, and eye symmetry. Conclusions: There are areas of nonequivalence between the 2 imaging methods; however, the differences are clinically acceptable from the orthodontic point of view. (Am J Orthod Dentofacial Orthop 2013;144:672-81)

he relationship between symmetry and attractiveness of the face is well documented.1,2 Farkas3 noted the importance of paired and angular measurements in detecting asymmetries as well as quantifying the face. In clinical practice, disharmonies, even if belonging to the borderline values of the normal range statistically, might create visually the impression of moderate disproportions.3

a Resident, Department of Orthodontics and Oral Facial Genetics, School of Dentistry, University of Indiana, Indianapolis, Ind. b Professor, Department of Orthodontics and Oral Facial Genetics, School of Dentistry, University of Indiana, Indianapolis, Ind. c Biostatistician supervisor, Department of Biostatistics, School of Medicine, University of Indiana, Indianapolis, Ind. d Assistant professor, Department of Orthodontics and Oral Facial Genetics, School of Dentistry, University of Indiana, Indianapolis, Ind; lecturer, Department of Orthodontics, Faculty of Dental Medicine, Al-Azhar University, Cairo, Egypt. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported. Funded by the Craniofacial Complex Center of Indiana University-Purdue University and the Jarabak Endowed Professorship. Address correspondence to: Ahmed A. Ghoneima, Department of Orthodontics and Oral Facial Genetics, Indiana University School of Dentistry, 1121 W Michigan St, Indianapolis, IN 46202; e-mail, aghoneim@iu.edu. Submitted, April 2013; revised and accepted, July 2013. 0889-5406/$36.00 Copyright 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.07.007

Objective evaluation of the soft tissues of the face is integral to effective treatment planning, postoperative assessment, and describing patterns of craniofacial growth and variation.4,5 The bony and dental framework supports the soft tissues of the face, which provides subtle and sometimes glaring information concerning the positioning of the framework. In the face, asymmetry can be produced either by defects of the underlying skeleton that can disrupt identication of the bony landmarks along the facial framework and midaxis of the face, or by disgurements in the soft-tissue structures affecting the location of the soft-tissue landmarks.3 Facial analysis has rapidly become the determinant of many orthodontic treatment choices.6 Although there are many limitations to what clinicians can do to change the soft tissues with orthodontic treatment, the soft tissues ultimately direct the treatment decisions. Assessing the intricate details of a patient's facial anatomy in 3 dimensions has traditionally been limited to evaluating the patient clinically. New technology has been introduced to evaluate the patient's 3-dimensional (3D) anatomic relationships.7 These advances in imaging have substantially enhanced the clinician's diagnostic ability and, at the same time, obviated the need for exposing patients to extra ionizing radiation in many cases.8

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The aims of this study were to investigate the equivalence of soft-tissue data from 3dMD photographic imaging compared with that produced via soft-tissue segmentation from 3D CBCT images and to determine whether both methods can be used interchangeably and accurately for orthodontic esthetic treatment planning.
MATERIAL AND METHODS

This retrospective study was performed with 70 3dMD images and 70 CBCT scans for the same subjects. The 70 participants consisted of 15 women with a mean age of 22.0 6 2.3 years and 55 men with a mean age of 22.9 6 4.1 years. They were a convenience sample of trumpet players who consented to participate in a prior study completed by the Department of Orthodontics at the School of Dentistry of Indiana University. The 3dMD system was used to capture each subject's 3D facial images. All subjects were positioned equidistant from each camera, which was set with a 1.5-ms capture speed. The i-CAT device (Imaging Sciences International, Hateld, Pa), used for all CBCT scans, was set with a 13-cm eld of view, 8.9-second scanning time, and 0.3 voxel scanning resolution. The images were taken within 30 minutes apart to minimize softtissue changes. All images were stored on secure computers in the Craniofacial Complex Center at the School of Dentistry of Indiana University. The parameters were selected based on previous studies of soft-tissue landmarks (Table I).3,9,10 The 3dMD photographic images and the segmented softtissue 3D CBCT images were coded and randomized to blind the investigator (T.E.M.) who was making the measurements. The images were registered, superimposed, and analyzed using Vultus software (3dMD). For each subject, a soft-tissue segmented view of the CBCT data was created by adjusting the threshold and Hounseld units to the closest soft-tissue segmentation amount (Fig 1). This process was done on all images in the same way and by the same investigator. The Hounseld units value was preset at 999.0 in the 3dMD software for skin segmentation and was then adjusted if the segmentation was unsatisfactory. The skin segmentation view was further rened by choosing the initial renement tool that is integrated in the software to remove the noise and excess areas that were not used in measurements (Fig 2). Using the reference plane tool, hard-tissue reference planes were established rst on each CBCT image showing the underlying skeletal structures. The midsagittal plane ran through nasion-anterior nasal spine-basion, the coronal plane passed through the most posterior and superior point

of the condylar head, and the axial plane passed through porion and orbitale (Frankfort horizontal plane). To standardize the position of each set of images, the segmented soft-tissue surface and the 3dMD photographic image were then superimposed by moving the 3dMD image manually onto the screen to coincide with the segmented soft-tissue surface of the CBCT image. The translucency of the 3dMD photograph was decreased to visualize the segmented soft-tissue surface data through the 3dMD data (Fig 3). This process was performed from 3 planes (sagittal, coronal, and axial) to obtain the most accurate manual alignment between the images. The hard-tissue reference planes were matched on the soft-tissue CBCT image and the 3dMD photographic image and locked in position (Fig 4). Landmarks were identied, and parameters were measured on each CBCT and 3dMD image separately using software measurement tools such as landmarking (soft-tissue landmarks) and calipers (distance and angular measurements) (Fig 5). Reliability was assessed by measuring the selected parameters of 10 randomly selected subjects. After registration and superimposition of the CBCT and 3dMD photographic images, the landmarks and the linear and angular parameters were identied on both the 3dMD images and the segmented soft-tissue surfaces of the CBCT images. All parameters were measured again by the same investigator 2 weeks later using the same workstation. The images were coded and randomized, and the primary investigator (T.E.M.) was blinded to the identity of the subjects. Measurements on the previous 10 subjects were repeated by a second investigator (A.A.G.) and compared for validity.
Statistical analysis

The images in the reliability study were analyzed using intraclass correlation coefcients and Bland-Altman plots to assess intraexaminer repeatability and interexaminer agreement. Summary statistics (means, standard deviations, standard errors, and ranges) were calculated for all measurements from both the 3dMD photographs and the CBCT images. The differences between the measurements and the ratio of the measurements for the 2 methods were calculated and summarized. To demonstrate the equivalence of the 2 methods, the difference between them must have a 95% condence interval (CI) contained entirely within the equivalence limits dened for each measurement. The equivalence limits were dened based on the repeatability results for each measurement. With a sample size of 70 subjects, the study was designed to have 90% power to detect equivalence, using an equivalence range of 60.4 SD,

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Table I. Plane and angle measurements used in the study


Parameter Total facial height: N-Pg (mm) Upper facial height: N-Sn (mm) Lower facial height: Sn-Pg (mm) Vermilion height: LS-LI (mm) Mouth width: Ch(R)-Ch(L) (mm) Total facial width: Tr(R)-Tr(L) (mm) Upper lip to E-line: LS to E-line (mm) Lower lip to E-line: LI to E-line (mm) Mandibular position vertically: Point B to axial plane (mm) Maxillary position vertically: Point A to axial plane (mm) Mandibular position AP: Point B to coronal plane (mm) Maxillary position AP: Point A to coronal plane (mm) Mouth symmetry: Ch(R) and Ch(L) to midsagittal plane (mm) Ch(R) and Ch(L) to axial plane (mm) Soft-tissue lip thickness: LS to maxillary central incisor (mm) LI to mandibular central incisor (mm) Eye symmetry: Exoc(R) and Exoc(L) to midsagittal plane (mm) Exoc(R) and Exoc(L) to axial plane (mm) Mandible symmetry: Go(R) and Go(L) to midsagittal plane (mm) Go(R) and Go(L) to axial plane (mm) Facial angle: N-Pn-Pg ( ) Nasofacial angle: Pn-Sn-Pg ( ) Denition Vertical linear measurement of facial dimension as measured from nasion (N) to pogonion (Pg) Vertical linear measurement of upper facial dimension as measured from nasion (N) to subnasale (Sn) Vertical linear measurement of lower facial dimension as measured from subnasale (Sn) to pogonion (Pg) Vertical linear measurement of lips from most prominent point of upper lip or labrale superior (LS) to most prominent point of lower lip or labrale inferior (LI) Transverse linear measurement of mouth width from cheilion right Ch(R) to cheilion left Ch(L) Transverse linear measurement of facial width as measured from tragion right Tr(R) to tragion left Tr(L) Anteroposterior linear position of upper lip (LS) to plane extending from tip of nose to most prominent point of chin (E-line) Anteroposterior linear position of lower lip (LI) to plane extending from tip of nose to most prominent point of chin (E-line) Vertical linear position of the deepest midline concavity on the mandibular symphysis (Point B) to the axial plane Vertical linear position of the deepest midline concavity on the maxilla (Point A) Anteroposterior (AP) linear position of the deepest midline concavity on the mndibular symphysis (Point B) Anteroposterior (AP) linear position of the deepest midline concavity on the maxilla (Point A) Transverse and vertical linear comparison of cheilion right Ch(R) and cheilion left Ch(L) positions AP linear measurement of most prominent point of upper lip (LS) to maxillary central incisor and lower lip (LI) to mandibular central incisor Transverse and vertical linear comparison of exocanthion right (Exoc[R]) and exocanthion left (Exoc[L]) positions Transverse and vertical linear comparison of gonion right (Go[R]) and gonion left (Go[L]) positions Angular measurement of soft-tissue prole measured from nasion (N) to pronasale (Pn) to pogonion (Pg) Angular measurement of soft-tissue prole measured from pronasale (Pn) to subnasale (Sn) to pogonion (Pg)

assuming that the true difference between the methods was zero, and a 2-sided 5% signicance level. The results were determined to be clinically acceptable at an arbitrary value of 3 mm since interobserver error was less than 3 mm.
RESULTS

The reliability subjects were analyzed using intraclass correlation coefcients and Bland-Altman plots to assess intraexaminer repeatability and interexaminer agreement. Intrarater reliability was high for all values, whereas some measurements had lower interrater reliability values (lower facial height, vermilion height, maxillary position in the anteroposterior direction, eye symmetry to the midsagittal plane, and mandibular symmetry to the midsagittal plane).

Although 70 3dMD and CBCT images were used in this study, not all 28 data points were identiable for all subjects. Twenty-one of the 28 landmarks were measured on all 3dMD images, and 14 of the 28 landmarks were measured on all CBCT images. Summary statistics for all collected measurements were calculated for both the CBCT images and the 3dMD photographs (Table II). Statistically signicant differences were reported for the following measurements: vermilion height, mouth width, total facial width, mouth symmetry to axial plane), soft-tissue lip thickness, and eye symmetry (Table III). All other data points were equivalent based on the mean differences between the 2 methods. Only 2 measurements (eye measures) barely exceeded the arbitrarily selected standard of 3 mm of asymmetry.

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Fig 1. Soft-tissue segmentation process. DISCUSSION

In this study, matching of the hard-tissue reference planes of living subjects was important for consistency of image alignment. Fourie et al11 reported that the 3D scanning systems were accurate and reliable when compared with direct anthropometric measurements and validated the systems for clinical use. Although that study proved high levels of accuracy, the authors used cadavers (in contrast to our study) in which softtissue pull, opening of eyes, and other issues would not have been apparent. Kim et al12 also used cadavers to study the precision and accuracy of facial softtissue measurements using multiplanar reconstructed computed tomography images. They proved that multiplanar reconstructed computed tomography imaging reconstructed to align with the long axis of the punctures from the skin to the underlying bone is accurate. Although most (21 of 28) soft-tissue landmarks chosen were equivalent based on the mean difference between the 2 methods, there were areas of nonequivalence. The areas of nonequivalence generally consisted of measurements involving the mouth, eyes, and ears (vermilion height), mouth width, total facial width, mouth symmetry, soft-tissue lip thickness, and eye symmetry. Those areas of nonequivalence also represented

the lowest agreement ratios in repeatability and agreement testing. Measurements including data points cheilion, labrale superior, and labrale inferior showed the possibility of less predictable landmark identications because of illdened lip margins on the soft-tissue segmented CBCT images, as well as facial hair that caused blurring of landmark margins.13 Measurements involving tragion might have shown inconsistencies because of the 3dMD camera's inability to capture it in detail. In addition, eye symmetry in the vertical dimension could have been impacted by the difference in the 2 modalities. In the CBCT scan, the patients had their eyes closed because of the clinical safety protocol, whereas in the 3dMD photo the eyes were open. In some cases, a change in the soft-tissue muscle pull could cause a slight change in this landmark vertically that would impact the accuracy of the 3dMD measurements statistically. Incrapera et al14 concluded that future midtreatment soft-tissue evaluations can be carried out using a noninvasive imaging system such as 3dMD. Our study proved some limitations in data points compared with their study. The greatest difference in data was at softtissue pogonion; it might have been caused because the data point was located at the edge of the 3dMD eld

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Fig 2. Segmentation after initial renement.

of view and prone to light distortion. The same reason could explain the inconsistencies we found in softtissue measurements that included tragion, which also lies on the edge of the eld of view. Wong et al15 found that craniofacial anthropometry using the 3dMD system is valid and reliable compared with direct anthropometry and suggested that digital measurements of prolabial width might require direct marking before imaging to improve identication. We also found differences with this landmark that suggest inconsistent identication because of poorly dened philtral crests, facial hair, and obscured landmarks caused by the camera ash. Many areas of statistically signicant differences in our data involved landmarks near the philtrum or those that might have involved facial hair obstructing landmark identication such as cheilion right and left as well as tragion. Although our study shows good to excellent reliability in identication of landmarks without premarking the landmarks, the lack of statistical equivalence between the landmarks with lower reliability in both imaging modalities indicates the probable inuence of these factors. Identication of tragion might be improved through stitching of lateral and frontal images as well as plotting the soft-tissue bizygomatic point vs tragion if this data

point cannot be identied. In a study reviewing the Genex FaceCam system (Genex Technologies, Inc, Bethesda, Md), it was found that multiple captures can be stitched together into 1 composite during postprocessing; however, problems can arise from this process. Captures might not be obtained synchronously, and any change in expression has the potential for adding noise to the image.16 Our study was retrospective, and only the 180 eld of view 3dMD system was used. We could not use stitched imaging to increase the accuracy of tragion. Alternatively, the bizygomatic point can also be used as a valid soft-tissue alternative to tragion with practice in obtaining this landmark. Another factor possibly affecting the equivalency of the measurements is the length of time to record the images. The 3dMD photographic images were captured in 1.5 ms, whereas the CBCT scan required 8.9 seconds. The difference in time could have allowed a slight twitch of an eye or a mouth. The obvious lack of simultaneous capture of images could inuence eye or mouth landmarks. At this time, the inability to take simultaneous images is apparent because of physical limitations of the equipment. The manual superimposition of the 3D images with the Vultus software in our study was based on past

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Fig 3. Visualization of soft-tissue segmentation through 3dMD.

research by Maal et al.17 With surface registration methods, it is possible to superimpose 3D textured surface data on reconstructed 3D skin models. Maal et al focused on the accuracy of the registration process of the 3D images. Surface-based registrations produced more accurate results than the reference-based method in their study because the registrations were of the same subjects; similar to our study, the referencebased method was more accurate when different subjects were registered.18 Image fusion, registration of a 3D stereophotograph on a CBCT image, provides a precise photorealistic digital representation of the patient's face.17 After registration, the images were manually superimposed, and hard-tissue reference planes were matched between images. Clinicians dealing with the facial region encounter an increasing demand for treatment mainly based on esthetic requests rather than correction of functional problems.1 The paradigm shift in treatment basis also means that many clinicians have started to plan from the external prole, placing importance on the soft tissues of the face, largely to determine the boundaries of orthodontic treatment.19 The boundaries of dental compensation for a jaw discrepancy are established by several aspects of anteroposterior or transverse soft-

tissue relationships and functions.20 Orthodontists and maxillofacial and plastic surgeons should have a deep understanding of those quantiable, objective facial characteristics that are considered by the public as attractive.4 Littleeld et al21 evaluated the development of the 3D imaging systems (laser scanners, structured light, CCD systems, 3dMD) and their accuracy and found that they are safe and accurate ways of obtaining 3D images of the cranium. They also evaluated the limitations of the software and indicated that current systems cannot capture the intricate details of the ears, and a covering must be placed on the head during digitization of the image to eliminate problems with hair. In our study, a black head scarf was used to cover the subjects' hair. Although these limitations exist in the software, 3D imaging has a great clinical advantage. Along with the clinical benets, it has signicant potential as a research tool for documenting patient history and evaluating treatment. Since soft-tissue data from 3dMD photographic imaging can be considered clinically equivalent to that produced by soft-tissue segmentation from 3D CBCT images, the 3dMD system is expected to play an important role in soft-tissue evaluation throughout treatment

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Fig 4. Reference planes.

Fig 5. A, Frontal view; B, three quarter view showing the soft-tissue landmarks.

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Table II. Summary Statistics


Measurement Total facial height: N-Pg (mm) Upper facial height: N-Sn (mm) Lower facial height: Sn-Pg (mm) Vermilion height: LS-LI (mm) Mouth width: Ch(R)-Ch(L) (mm) Total facial width: Tr(R)-Tr(L) (mm) Upper lip to E-line: LS to E-line (mm) Lower lip to E-line: LI to E-line (mm) Mandibular position vertically: Point B to axial plane (mm) Maxillary position vertically: Point A to axial plane (mm) Mandibular position AP: Point B to coronal line (mm) Maxillary position AP: Point A to coronal line (mm) Mouth symmetry: Ch(R) to midsagittal plane (mm) Mouth symmetry: Ch(L) to midsagittal plane (mm) Mouth symmetry: Ch(R) to axial plane (mm) Mouth symmetry: Ch(L) to axial plane (mm) Soft-tissue lip thickness: LS to maxillary central incisor (mm) Soft-tissue lip thickness: LI to mandibular central incisor (mm) Eye symmetry: Exoc(R) to axial plane (mm) Eye symmetry: Exoc(L) to axial plane (mm) Eye symmetry: Exoc(R) to midsagittal plane (mm) Eye symmetry: Exoc(L) to midsagittal plane (mm) Mandible symmetry: Go(R) to axial plane (mm) Mandible symmetry: Go(L) to axial plane (mm) Mandible symmetry: Go(R) to midsagittal plane (mm) Mandible symmetry: Go(L) to midsagittal plane (mm) Facial angle: N-Pn-Pg ( ) Nasofacial angle: Pn-Sn-Pg ( ) Method 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT 3dMD CBCT Mean 114.6 113.9 53.7 54.2 62.1 61.1 15.5 16.2 50.0 47.8 145.0 146.9 5.5 6.0 3.9 4.2 64.2 63.7 29.6 29.9 98.5 97.9 102.1 101.1 25.0 24.0 24.5 22.7 49.4 48.3 48.9 47.9 30.4 28.7 30.2 27.9 16.9 13.8 17.2 14.1 46.2 45.6 44.7 43.7 68.8 68.8 68.5 68.6 60.7 59.7 59.3 59.0 129.3 129.2 138.9 137.9 SD 8.7 8.6 4.4 4.5 7.4 7.5 3.0 2.7 3.9 5.3 7.9 7.8 2.7 2.7 2.9 2.8 4.9 5.0 3.7 3.9 6.7 6.4 5.4 5.4 2.5 3.0 2.3 2.7 3.4 3.6 3.5 3.5 5.6 5.6 6.6 5.8 2.1 1.9 2.4 1.9 2.4 3.0 2.7 3.0 5.6 5.7 5.8 5.7 7.0 6.4 6.6 6.8 4.9 4.7 7.4 7.3 Minimum 94.7 95.5 45.8 44.6 44.4 43.2 9.0 11.2 37.0 36.0 128.9 131.2 2.7 2.0 2.9 3.0 54.9 53.2 22.2 22.0 84.0 82.4 90.5 89.7 20.0 17.7 16.3 16.3 43.2 39.1 41.3 39.2 18.6 17.1 18.6 16.9 12.0 9.8 11.3 9.6 40.9 39.1 39.1 37.0 51.9 50.3 48.2 48.5 51.5 51.9 50.2 48.9 115.4 115.3 121.8 121.1 Maximum 132.9 129.6 70.8 73.6 77.4 76.0 24.2 24.2 57.1 63.8 164.2 165.1 11.2 12.3 10.0 9.2 76.1 76.0 36.8 39.3 118.4 117.4 112.9 111.9 30.7 36.6 29.9 29.9 58.8 57.2 56.9 55.5 53.9 52.4 49.7 45.9 21.5 18.1 21.5 18.3 52.1 53.7 52.8 50.6 82.3 82.2 79.2 78.7 82.6 80.8 79.8 81.3 140.6 140.4 160.1 156.6

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Table III. Equivalence conclusions


Within-specimen SD for reliability Measurement Total facial height: N-Pg (mm) Upper facial height: N-Sn (mm) Lower facial height: Sn-Pg (mm) Vermilion height: LS-LI (mm) Mouth width: Ch(R) - Ch(L) (mm) Total facial width: Tr(R)-Tr(L) (mm) Upper lip to E-line: LS to E-line (mm) Lower lip to E-line: LI to E-line (mm) Mandibular position vertically: Point B to axial plane (mm) Maxillary position vertically: Point A to axial plane (mm) Mandibular position AP: Point B to coronal line (mm) Maxillary position AP: Point A to coronal line (mm) Mouth symmetry: Ch(R) to midsagittal plane (mm) Mouth symmetry: Ch(L) to midsagittal plane (mm) Mouth symmetry: Ch(R) to axial plane (mm) Mouth symmetry: Ch(L) to axial plane (mm) Soft-tissue lip thickness: LS maxillary central incisor (mm) Soft-tissue lip thickness: LI to mandibular central incisor (mm) Eye symmetry: Exoc(R) to axial plane (mm) Eye symmetry: Exoc(L) to axial plane (mm) Eye symmetry: Exoc(R) to midsagittal plane (mm) Eye symmetry: Exoc(L) to midsagittal plane (mm) Mandible symmetry: Go(R) to axial plane (mm) Mandible symmetry: Go(L) to axial plane (mm) Mandible symmetry: Go(R) to midsagittal plane (mm) Mandible symmetry: Go(L) to midsagittal plane (mm) Facial angle: N-Pn-Pg ( ) Nasofacial angle: Pn-Sn-Pg ( ) Y, Yes; N, no. Mean difference (95% CI) 0.6 (0.2, 0.9) 0.5 (0.8, 0.2) 1.0 (0.5, 1.4) 0.7 (1.1, 0.2) 2.2 (1.3, 3.0) 1.1 (1.6, 0.6) 0.4 (0.6, 0.1) 0.0 (0.3, 0.2) 0.5 (0.1, 0.8) 0.4 (0.7, 0.2) 0.6 (0.3, 1.0) 0.9 (0.6, 1.2) 1.0 (0.4, 1.5) 1.8 (1.3, 2.3) 1.1 (0.7, 1.5) 1.0 (0.7, 1.4) 1.7 (1.1, 2.4) 2.2 (1.2, 3.2) 3.2 (2.8, 3.6) 3.1 (2.7, 3.5) 0.6 (0.1, 1.1) 1.0 (0.5, 1.4) 0.0 (0.2, 0.2) 0.1 (0.3, 0.1) 1.0 (0.6, 1.3) 0.3 (0.0, 0.7) 0.4 (0.0, 0.8) 0.4 (0.0, 0.8) 3dMD 1.25 0.74 1.10 0.65 1.04 1.14 0.42 0.59 1.09 1.06 1.32 0.93 1.08 1.01 1.02 1.18 1.69 1.72 0.82 1.27 0.71 1.18 1.47 1.27 1.12 1.26 1.13 1.10 CBCT 1.15 0.83 0.90 0.52 0.98 0.66 0.39 0.44 0.87 0.97 1.20 1.02 1.15 1.45 0.60 1.23 1.22 1.01 0.75 0.50 0.82 0.91 1.03 1.36 1.20 1.52 1.57 1.23 Equivalence range dened Equivalent based using 23withinon difference specimen SD between methods 2.3 Y 1.7 Y 1.8 Y 1.0 N 2.0 N 1.3 N 0.8 Y 0.9 Y 1.7 Y 1.9 Y 2.4 Y 2.0 Y 2.3 Y 2.9 Y 1.2 N 2.5 Y 2.4 Y 2.0 N 1.5 N 1.0 N 1.6 Y 1.8 Y 2.1 Y 2.7 Y 2.4 Y 3.0 Y 3.1 Y 2.5 Y

to reduce the need for exposing the patient to extra radiation.


CONCLUSIONS

The evaluated systems (3dMD and segmented softtissue images from CBCT) can be used interchangeably for orthodontic treatment planning because both imaging modalities provide similar representations of the soft-tissue anatomy. Although a few landmarks showed statistically signicant differences, these are clinically acceptable from the orthodontic point of view. Since it is difcult to determine the soft tissues in CBCT images, future midcourse evaluations of soft tissues could be made accurately with the 3dMD system, providing an alternative method for soft-tissue evaluation with no radiation exposure.
REFERENCES 1. Sforza C, Laino A, D'Alessio R, Grandi G, Tartaglia GM, Ferrario VF. Soft-tissue facial characteristics of attractive and normal adolescent boys and girls. Angle Orthod 2008;78:799-807.

2. Islam R, Kitahara T, Naher L, Hara A, Nakasima A. Lip morphological changes in orthodontic treatment. Class II division 1: malocclusion and normal occlusion at rest and on smiling. Angle Orthod 2009;79:256-64. 3. Farkas L. Anthropometry of the head and face. New York: Raven Press; 1994. 4. Weinberg SM, Naidoo S, Govier DP, Martin RA, Kane AA, Marazita ML. Anthropometric precision and accuracy of digital three-dimensional photogrammetry: comparing the Genex and 3dMD imaging systems with one another and with direct anthropometry. J Craniofac Surg 2006;17:477-83. 5. Primozic J, Perinetti G, Richmond S, Ovsenik M. Three-dimensional evaluation of facial asymmetry in association with unilateral functional crossbite in the primary, early, and late mixed dentition phases. Angle Orthod 2013;83:253-8. 6. Sarver DM. The face as the determinant of treatment choice. In: McNamara J, Kelly KA, editors. Frontiers of dental and facial esthetics. Ann Arbor, Mich; 2001. p. 19-54. 7. Harrell W Jr. Three-dimensional diagnosis and treatment planning: the use of 3D facial imaging and 3D cone beam CT in orthodontics and dentistry. Aust Dent Pract 2007:102-13. 8. Quintero JC, Trosien A, Hatcher D, Kapila S. Craniofacial imaging in orthodontics: historical perspective, current status, and future developments. Angle Orthod 1999;69:491-506. 9. Babbush CA. Mosby's dental dictionary. St Louis: Mosby; 2008.

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10. Schneider U, Pedroni E, Lomax A. The calibration of CT Hounseld units for radiotherapy treatment planning. Phys Med Biol 1996; 41:111-24. 11. Fourie Z, Damstra J, Gerrits PO, Ren Y. Evaluation of anthropometric accuracy and reliability using different three-dimensional scanning systems. Forensic Sci Int 2011;207:127-34. 12. Kim KD, Ruprecht A, Wang G, Lee JB, Dawson DV, Vannier MW. Accuracy of facial soft tissue thickness measurements in personal computer-based multiplanar reconstructed computed tomographic images. Forensic Sci Int 2005;155:28-34. 13. Aynechi N, Larson BE, Leon-Salazar V, Beiraghi S. Accuracy and precision of a 3D anthropometric facial analysis with and without landmark labeling before image acquisition. Angle Orthod 2011; 81:245-52. 14. Incrapera AK, Kau CH, English JD, McGrory K, Sarver DM. Soft tissue images from cephalograms compared with those from a 3D surface acquisition system. Angle Orthod 2010;80:58-64. 15. Wong JY, Oh AK, Ohta E, Hunt AT, Rogers GF, Mulliken JB, et al. Validity and reliability of craniofacial anthropometric measurement of 3D digital photogrammetric images. Cleft Palate Craniofac J 2008;45:232-9. 16. Weinberg SM, Neiswanger K, Richtsmeier JT, Maher BS, Mooney MP, Siegel MI, et al. Three-dimensional morphometric

17.

18.

19.

20.

21.

analysis of craniofacial shape in the unaffected relatives of individuals with nonsyndromic orofacial clefts: a possible marker for genetic susceptibility. Am J Med Genet A 2008;146A: 409-20. Maal TJ, Plooij JM, Rangel FA, Mollemans W, Schutyser FA, Berge SJ. The accuracy of matching three-dimensional photographs with skin surfaces derived from cone-beam computed tomography. Int J Oral Maxillofac Surg 2008;37: 641-6. Maal TJ, van Loon B, Plooij JM, Rangel F, Ettema AM, Borstlap WA, et al. Registration of 3-dimensional facial photographs for clinical use. J Oral Maxillofac Surg 2010;68: 2391-401. Kau CH, Richmond S, Zhurov A, Ovsenik M, Tawk W, Borbely P, et al. Use of 3-dimensional surface acquisition to study facial morphology in 5 populations. Am J Orthod Dentofacial Orthop 2010;137(Suppl):S56.e1-9. Ackerman JL, Proft WR, Sarver DM. The emerging soft tissue paradigm in orthodontic diagnosis and treatment planning. Clin Orthod Res 1999;2:49-52. Littleeld TR, Kelly KM, Cherney JC, Beals SP, Pomatto JK. Development of a new three-dimensional cranial imaging system. J Craniofac Surg 2004;15:175-81.

American Journal of Orthodontics and Dentofacial Orthopedics

November 2013  Vol 144  Issue 5