The Virtual Patient Specific-Model and the

Virtual Dental Model

Vicente Hernndez-Soler, Reyes Enciso, and George J. Cisneros
The current trend in orthodontic records is toward an integrated virtual
3-dimensional (3D) model with soft tissue, hard tissue, and dentition. An
important part of this complete 3D record is the dental model. Cone beam
computed tomography allows the taking of all radiographic records and the
creation of virtual dental models out of a single scan. The virtual dental
models created out of cone beam computed tomography come with significant diagnostic additions, changing the way electronic casts are used.
(Semin Orthod 2011;17:46-48.) Crown Copyright 2011 Published by
Elsevier Inc. All rights reserved.

ince the early 1930s the classical orthodontic patient documentation consisted of a lateral head film, orthopantomogram, facial and
dental photographs, and plaster casts. Contemporary trends in imaging, such as cone beam
computed tomography (CBCT), allow a change
from datasets of records toward a so-called virtual patient-specific model (VPSM). The VPSM
is the integration of all datasets into a single
patient record.1
The VPSM via the use of CBCT provides 3-dimensional 1:1 accurate information, which can
be viewed as traditional CTs in a slice-by-slice
mode. This cross-sectional viewing capability
may improve orthodontic diagnosis and treatment planning. Coronal slices may better differentiate transverse problems, such as a skeletal
versus a dental cross-bite. Asymmetries can be
further classified into anterior-posterior and vertical and that could change treatment plans.
Problems, such as condylar hyperplasia or mid-

Associate Professor, Valencia University, Spain; Clinical Assistant Professor, Division of Endodontics, Oral Maxillofacial Surgery
and Orthodontics, School of Dentistry, University of Southern California, Los Angeles, CA; Professor, Department of Orthodontics,
College of Dentistry, New York University, New York, NY.
Address correspondence to Dr Vicente Hernndez-Soler, Deportista
Andres Muoz, Alicante 03003, Spain. E-mail: vicente@vicentehernandez.com
Crown Copyright 2011 Published by Elsevier Inc. All rights
reserved.
1073-8746/11/1701-0$30.00/0
doi:10.1053/j.sodo.2010.08.009

46

face asymmetry caused by maxillary canting, can

be quantified and assessed more accurately with
a 3D model.
An important part of the VPSM is the virtual
dental model (VDM). Compared with a plaster
model, the VDM has the all the advantages of a
digital format, which include, ease of access,
digital storage (which requires little physical
space), and ease of transfer to colleagues and
insurances or other offices, among others. The
VDM can be created by direct or indirect methods. Indirect methods, as the name implies, requires additional steps, such as impressions and
pouring of models in plaster, before its capture
into a digital format. The scanning of an impression or plaster cast can be done by a laser scanner, structured light, or even radiographic methods. Digital dental models created from dental
cast scans or dental impression scans have
proven to be as reliable as plasters models.2 For
the indirect methods, the transition from physical to digital records brings all the digital format
advantages but no significant additional diagnostic data. Plaster models may even offer more
diagnostic data because by holding the cast and
occluding both arches, the feel of the occlusion as stable or unstable can be assessed.
In the digital format, an attempt to replicate
such capability is represented as location and
shape of occlusal points and surfaces, but such
information may be more difficult to interpret
(Fig 1). Perhaps the major advantage of these
VDMs is the virtual setup capabilities, where ex-

Seminars in Orthodontics, Vol 17, No 1 (March), 2011: pp 46-48

Virtual Patient Specific-Model and the Virtual Dental Model

47

Figure 1. Occlusogram showing size and location of occlusal contacts between both arches. (Courtesy of
Geodigm Co, Chanhassen, MN.) (Color version of figure is available online.)

traction versus nonextraction treatment plans

can be compared, and the result visualized in a
faster and more practical way than having to use
laboratory saws and multiple dental impressions.
The direct methods for the creation of VDMs
are either the direct scan of the dentition with
an intraoral scanner using structured light, or
radiographic data, such as the CBCT. The VDM
derived from a CBCT, because the origin is radiographic data, includes not only the crowns
but also the roots of the teeth as well as any
unerupted or impacted teeth (Fig 2). The
CBCT-derived VDMs offers more than surfaceonly data because CBCT-derived VDMs allow for
3dimensional data and not only surface data.
The CBCT-derived VDM thus permits evaluation
of internal anatomy, which other methods do
not.
VDMs from CBCT have all the advantages of
the indirect method, with the additional diagnostic information of root position, root shape,
bone level, internal dental anatomy, relationship
to anatomic structures, such as the mandibular
nerve, as well as quantitative bone density information. Crown to root ratios can be estimated,

and tooth measurements can be performed even

before the teeth erupt. The virtual dental
setup now also includes the roots, which allow
for torque and labiolingual inclination in the
dental setup.
For VDMs derived from a CBCT, depending
on the scanner, the user has the choice of imaging the target area with different settings, such as
field of view, resolution (voxel size), milliamperage (mA), kilovoltage (kVp), among others. The
slice thickness from currently available scanners
ranges from 0.076 to 1 mm, depending on the
model and the manufacturer of the scanner.
Radiological machine settings used for scans
aimed at answering the same diagnostic question range from 1 to 15 mA. Scans made at
different imaging centers or offices for similar
problems, for example an impacted tooth, may
be exposed to different exposure levels depending on the brand of the scanner used. Altering
scanner parameters have a direct effect on image quality. It is essential to acquire high-quality
imaging data, because all other construction
steps depend upon these data. For higher image
quality, often greater radiation exposure is

48

Hernndez-Soler, Enciso, and Cisneros

Figure 2. Electronic model created from a CBCT

image. (Courtesy of Anatomage, Inc, San Jose, CA.)

needed. A balance between image quality and

radiation exposure is the operators responsibility. This balance means that the image should be
able to answer all required diagnostic questions,
taken with the lowest possible radiation exposure to the patient. This is referred to as the As
Low As Reasonably Achievable principle. Image
taking protocols need to be developed to
achieve the best possible balance between image
quality and radiation exposure.
Conventional lateral cephalograms are taken
with teeth in occlusion. If a CBCT is taken with
teeth in occlusion, the segmentation (separation) of maxillary and mandibular teeth becomes more difficult because the cusps of antagonist teeth would overlap. Teeth in occlusion
scans make it more difficult to build an accurate
dental model as they reduce the visibility of
teeth surfaces. Possible solutions include the use
of a thin wax-bite during scanning which may
facilitate the separation between the maxilla and
the mandible during the processing, causing little effect to the vertical dimension. If the image

is taken with the teeth in occlusion, occlusal

anatomy libraries, which match the tooth size,
can be used for more visually appealing toothlike images. The use of occlusal anatomy libraries is however more for esthetic value than
for diagnostic ability.
Dental restorations, such as amalgams or
crowns can create slight image artifacts in CBCT
images. Orthodontic appliances produce lesser
artifacts than dental restorations but also may
interfere with the views of dental occlusal anatomy. If true occlusal surface anatomy details are
necessary, the image may be supplemented with
an additional CBCT, or a hand-held oral scanning image.3 A composite or augmented model
with fusion data from different sources, because
they represent different time points, require
careful registration, verification, and validation.
The VPSM does not necessarily need to be a
static representation. The next development in
diagnostic data is the incorporation of motion to
the VPSM model. This motion can now be supplemented by dynamic records, such as jaw
tracking or video clips motions.1 To be consistent with medical image standards, and facilitate
interoperability, all images needs to be in a
DICOM format (ie, Digital Imaging and Communications in Medicine).

Conclusions
The present article describes how the virtual
dental model derived from CBCT not only incorporates all radiographic and dental cast information into a single scan, but also provides
significantly more information, adding internal
anatomy and the roots of the teeth into the
electronic dental model.

References
1. Enciso R, Memon A, Fidaleo DA, et al: The virtual cranio
facial patient: 3D jaw modeling and animation. Stud
Health Technol Inform 94:65-71, 2003
2. Dalstra M, Melsen B: From alginate impressions to virtual
digital models. J Orthod 36:36-41, 2009
3. http://www.cadentinc.com/. Accessed August 26, 2009