The Future of Orthodontic Diagnostic Records

Chung How Kau, Sarah Olim, and Jennifer T. Nguyen

The use of 3-dimensional (3D) diagnostic records can be an extremely valuable tool. These records can accurately reproduce a patient dataset in a
secondary environment, and when appropriately interfaced, allow the practitioner the ability to create and manipulate these records as a 3D virtual
patient. Stereophotogrammetry images were obtained from the 3dMD
system (Atlanta, GA), and this system produces a full-face image in 1.5 ms
by the use of an active stereo approach. Cone beam computed tomography
images from the Sirona Galileos System (Charlotte, NC) provide the base
and internal volume onto which a 3dMD image can be overlaid. In both
image acquisition systems, natural head posture was adopted for all subjects, as this has been proven to be clinically reproducible. 3dMDvultus was
the software platform that allowed visualization and fusion of the 2 imaging
modalities. In vivo Dental was used to create the cone beam computerized
tomography study models. The relative ease of reconstructing the 3D virtual
represents the right step forward in orthodontic diagnosis and treatment
planning. With the cost and increase in speed for acquiring and reproducing
images, 3D virtual record will one day replace current methods of orthodontic record taking. (Semin Orthod 2011;17:39-45.) 2011 Elsevier Inc. All
rights reserved.

he use of 3-dimensional (3D) diagnostic

records can be an extremely valuable tool.
These records can accurately reproduce a patient dataset in a secondary environment, and
when appropriately interfaced, allow the practitioner the ability to create and manipulate these
records as a 3D virtual patient. Both the practitioner and patient can benefit from the development of these new technologies because they
can provide a more accurate platform for diagnosing and treatment planning, and be a valuable tool for patient education.

Professor and Chair, Department of Orthodontics, University of

Alabama at Birmingham, Birmingham, AL; Pre-Doctoral Student,
Department of Orthodontics, University of Texas Health Science
Center at Houston Dental Branch, Houston, TX; Research Assistant, Department of Orthodontics, University of Texas Health Science Center at Houston Dental Branch, Houston, TX.
Address correspondence to Dr Chung How Kau, Professor and
Chair, Department of Orthodontics, University of Alabama at Birmingham, SDB 305, Box 57, 1530 3rd Ave S, Birmingham, AL
35294-0007. E-mail: ckau@uab.edu
2011 Elsevier Inc. All rights reserved.
1073-8746/11/1701-0$30.00/0
doi:10.1053/j.sodo.2010.08.008

Historically, orthodontic patient records (excluding cast stone dental models) have been
analogue, 2-dimensional works in differing mediums with a variety of inherent magnification, subject-movement, and equipment-based (streaking
and artifact) errors. The traditional records in an
orthodontic office include clinical photographs,
a set of radiographs (namely the lateral cephalogram and panoramic radiographs), and plaster dental models.
Extraoral photographs are limited in their
ability to capture a true 3D image; therefore, a
series of standardized images are taken. Photographs, lateral cephalograms, and panoramic radiographs are confined to 2D representations,
which increases the chance of clinical inaccuracy
because the information is contained within the
single-plane image.1 In retrospect, a human being is a volumetric dataset, and with a 2D representation, information is lost in the compression.2 In addition, dental plaster models require
chair-side time and large amounts of space for
storage. At present, orthodontic records are
taken based on the clinically perceived complex-

Seminars in Orthodontics, Vol 17, No 1 (March), 2011: pp 39-45

39

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Kau, Olim, and Nguyen

ity of the case,3 and it is possible that some of

these may be omitted in certain circumstances.

plan further treatment.14 This work describes

the use of 3D technology in the creation of the
3D diagnostic record.

Revolutionary Technologies
Todays 3D diagnostic imaging provides a novel
platform for orthodontic diagnosing and treatment planning through use of radiation (cone
beam computed tomography [CBCT])4,5 and
surface imaging.6
CBCTs for dental, oral and maxillofacial, and
orthodontic uses were designed to counter some
of the limitations of high-radiation based conventional CT scanning devices. The radiation
source consists of a conventional low-radiation
X-ray tube, and the resultant beam is projected
onto a panel detector. The cone beam produces
a more focused beam and much less radiation
scatter compared with the conventional fanshaped CT devices.7 These enhancements significantly increase use of X-rays and reduce the
X-ray tube capacity required for volumetric scanning.8 It has been reported that the total radiation is approximately 20% of conventional CTs
and equivalent to a full mouth periapical radiographic exposure.9
Dental CBCT can be recommended as a dosesparing technique compared with alternative
standard medical CT scans for common oral and
maxillofacial radiographic imaging tasks.10 Researchers have shown that volumetric scanning
radiographically gives the clinician a nearly exact 1:1 image-to-reality ratio when used with
appropriate algorithms.11 This allows for greater
precision for planning complex surgical cases,
including canine impactions in 3D.12
Furthermore, stereophotogrammetry is used
as a surface acquisition device to overlay the
CBCT image file with specific anchor points.
CBCT does not create an ideal soft-tissue texture; therefore, the addition of the stereophotogrammetry can communicate the full volume of
the face to the viewer.4 Because the profound
skeletal changes created during orthodontic
treatment affect a patient in more than just the
anteroposterior dimension,2 seeing a patients
full face in superimposition can show positive or
negative volumetric changes, especially postsurgically.13 Finally, CBCT can be used to generate
3D digital models of the dentition via software,
such as in vivo (Anatomage Inc, San Jose, CA).
These can then be used to create appliances or

Subject and Methods

The following image acquisition systems and
software were used in the study.

Stereophotogrammetry
Stereophotogrammetry images were obtained
from the 3dMD system (Atlanta, GA), which
produces a full-face image in 1.5 ms by the use of
an active stereo approach13 that helps eliminate
ambient spectral interference and helps image a
range of skin tones and clothing colors. The
machines 6 medical-grade cameras take images
that become a stereo pair at a specific depth.
Three-dimensional data clouds derived from the
predetermined stereo triangulation algorithms
are extracted to match external surface features
and then generate a 3D composite model.6 Natural landmarks and patterns are combined with
data obtained from the structured light projection to provide adequate data for the most accurate geometry possible. The color texture is layered over this geometry and provides a mostly
esthetic benefit. In addition, the hairline is generally a stopping point for most systems as it is
difficult to accurately capture each strand,
though well-groomed facial hair does not usually
affect the outcome of a scan.2 Images are stored
as proprietary software versions as *.tsb files
from the 3dMD files.

CBCT
CBCT images (GalileosSirona Dental Systems
LLC, Charlotte, NC) provide the base and internal volume onto which a 3dMD image can be
overlaid. CBCT is an impressive, if not ideal,
technology for this diagnostic record and continues to evolve and improve. CBCT technology
uses x-rays and delivers a lower, although still
relatively controversial (in both actual quantity
and safety), dose of radiation between approximately 60 and 1000 Sv.15 In less than 20 seconds, the machine performs a single 180- or
360-degree rotation around the patient by the
use of a conventional low-radiation x-ray tube
that focuses the beam on a flat-panel detector or
charge-coupled device and causes minimal radi-

Future of Orthodontic Diagnostic Records

ation scatter, reducing the radiation required

for scanning compared with conventional CT.
Raw data are stored in Digital Imaging and Communications in Medicine (DICOM) file formats.

Image Acquisition
In both image acquisition systems, the natural
head posture (NHP) was adopted for all subjects, because this has been proven to be clinically reproducible.16 The subjects sat on the adjustable chair and were asked to look into a
mirror with a horizontal and vertical line
marked on it. They were asked to level their eyes
to the horizontal line and to adjust the midline
of their faces to line up with the vertical line.
Adjustments to seating heights were made to
assist the subjects in achieving NHP. The subjects were asked to swallow hard and to keep
their jaws in a relaxed position just before the
images were taken. Each image acquisition took
1.5 ms for the stereophotogrammetry device and
14 s for the CBCT device.

Image and Data Rendering

dMDvultus Software
dMDvultus (3dMD) is a new software platform
that allows users an easy-to-use, 3D patient treat-

41

ment visualization platform built on an industrial strength communication platform. Exploiting the principle of Image Fusion, 3dMDvultus
fuses the 3dMD surface with the CT/CBCT/
digitized dental study models to present information to assess patient treatment options where
it is easy to support the review of the patient
condition, and then plan and simulate possible
treatment and surgery, monitor actual images of
progress and make evaluations of outcomes. Fusion of the stereophotogrammetric surface to
the surface rendered on the CBCT is performed
by the use of the iterative closest point algorithm
or best-fit method, which has been used and
reported previously (Fig 1).17,18

InVivoDental Software for CBCT Digital Study

Model Acquisition
InVivoDental (Anatomage, San Jose, CA) software was used to create study models from
CBCT scans taken by a Galileos cone beam
scanner (Sirona, Charlotte, NC) with a field of
view of 15 15 15 cm3 and a voxel resolution of 0.125 mm. CBCT images were electronically sent via a secure Web site to the company
Anatomage in a DICOM format. A volumerendering software converted these files and a
final 3D-generated model of the teeth was pro-

Figure 1. Series of images obtained from the 3dMDVultus software depicting the skeletal and hard tissues
images obtained from the surface acquisition system and CBCT device. The root mean square error in merging
both datasets was 0.346 mm. (Color version of figure is available online.)

42

Kau, Olim, and Nguyen

duced, and analysis was made on a proprietary

software package.

Discussion and the Future

Clinical orthodontic evaluation and diagnosis
have undergone enormous changes in the last
20 years. For example, the number of manufacturers and devices in which CBCT technology is
used is growing rapidly. The authors of a recent
overview found 16 manufacturers and 23 devices
using the CBCT technique applied to the maxillofacial region.19 The important differences between the devices are their field of view,20 the
irradiation dose, size and weight, time needed
for the reconstruction, voxel size,21 scanning
time, price, software, and warranty. In general,
higher resolution images require a greater scan
time. This often means that more slice images
are obtained during the scanning process. The
use of CBCT and stereophotogrammetry has
many implications.

Clinical Applications of the Virtual Record

Facial Growth
The traditional measure to assess facial growth is
by lateral cephalograms measuring 2D landmarks that arguably do not exist in a 3D patient.22,23 The 3D virtual record allows serial
capture of faces that may be analyzed at a later
stage. These images maybe overlaid on one another on known structures to determine the surface changes and to correlate them to growth.
Some examples have been provided for in
growth studies24 using surface imaging. It can
also be easily reproduced for virtual record.
Craniofacial Anomalies
Surface imaging has been used to create the
average faces. These techniques can be easily used
in the 3D virtual record. The average facial meshes
may be used as a template to determine morphologic differences between normal subjects25 and
those with craniofacial anomalies.26,27 In addition,
templates have been used to identify differences in
faces in multiple populations.28,29
Orthognathic Surgery
Another area of interest to a multidisciplinary
group of clinicians is the study of soft tissue

changes associated with orthognathic surgery.

The authors of previous studies have described
the changes in soft-tissue dimensions after surgery by plotting linear measurements following
treatment on landmark based points.30 Others
have compared treatment changes between
groups of normal adults and those with facial
disproportion31 by comparing the color codes
on facial deviation maps. Recently, studies have
also compared facial asymmetry before and after
surgery.32 To optimize the advancement in technology, some studies have also attempted to
combine hard and soft tissue data imaging techniques.33,34
All these improvements in software applications
have meant that validation and quantification of
volumetric changes after routine oral and maxillofacial surgery can be attempted easily.35-37 The
results presented in this study showed that the
amount of surface swelling reduces approximately by 60% in individuals within a month
after surgery. It also showed that bimaxillary jaw
surgery produces a greater amount of swelling
but reduces at a faster rate than single jaw surgery. Furthermore, facial morphology recovered
to approximately 83% in 3 months.
Other Applications of Surface Acquisition
Systems
Surface imaging has also been combined in part
with traditional CT imaging to create a novel
and image guided surgery. Marmulla and coworkers38,39 described the use of a high-resolution
laser surface scanning device (Minolta vi-910) for
patient registration in cranial computer-assisted
surgery. Surface registration was performed by the
navigational system Surgical Segment Navigation
(SSN), which uses infrared transmission technology enlarged by the laser scanner.38 This allows
the laser coordinate system to calibrate with the
infrared system to navigate infrared transmitting
instruments. This technique has been successfully applied in the study of 22 patients.
Creation of Study Models from CBCT
Images
A study using CBCT study models has shown
promising results when the Littles index measurements were used.40 The results from that
study showed small difference between measurements made from OrthoCAD (Cadent, Inc, Carl-

Future of Orthodontic Diagnostic Records

43

Figure 2. A series of images showing the acquisition of study models directly from CBCT images. (Color version
of figure is available online.)

stadt, NJ) models and CBCT-generated models.

In addition, the study showed that digital models
generated from CBCT imaging not only offer
diagnostic information but other information,
such as bone levels, root positions, and temporomandibular joint status are also captured. These
are not present on OrthoCAD models. Orthodontists can also eliminate the use of dental
impression materials for diagnostic casts. If, however, the clinician needs an indirect set up, they
must take an impression for that purpose. The
idea of gathering all diagnostic records from a
single CBCT scan is most intriguing to the orthodontic profession. As the computer technology
improves, the occlusal distortion in the CBCT
models should also improve. With the constantly
improving CBCT technology, the ability to
gather all diagnostic records from a single CBCT
scan seems imminent (Fig 2).

orthodontists. It has pushed the learning curve

for clinicians and allowed tools to be created for
the future. Many 3D imaging devices are available for soft tissue and hard imaging. New techniques and sophisticated software tools now allow clinicians to manipulate the images and to
make them relevant to the clinical setting.

Future Directions

Conclusions

These advancements in technology have added

valuable information to this topic of interests to

The relative ease of reconstructing the 3D virtual

represents the right step forward in orthodontic

Nonradiation Machines
The use of magnetic resonance imaging as a
possible 3D diagnostic tool may be explored in
the future as it poses no threat of ionizing radiation to the patient. It is a good tool for showing
detailed images of soft-tissue structures, including
the sinuses and TMJ; these images are captured
with a large electromagnet and radio receiverbased unit. However, it is currently extremely costprohibitive and time-consuming.41

44

Kau, Olim, and Nguyen

diagnosis and treatment planning. With the cost

and increase in speed for acquiring and reproducing images, 3D virtual record will one day
replace current methods of orthodontic record
taking.

References
1. Caloss R, Atkins K, Stella JP: Three-dimensional imaging
for virtual assessment and treatment simulation in orthognathic surgery. Oral Maxillofac Surg Clin North Am
19:287-309, 2007
2. Lane C, Harrell W Jr: Completing the 3-dimensional
picture. Am J Orthod Dentofac Orthop 133:612-620,
2008
3. Nijkamp PG, Habets LL, Aartman IH, et al: The influence of cephalometrics on orthodontic treatment planning. Eur J Orthod 30:630-635, 2008
4. Kau CH, Richmond S, Palomo JM, et al: Three-dimensional cone beam computerized tomography in orthodontics. J Orthod 32:282-293, 2005
5. Palomo JM, Kau CH, Palomo LB, et al: Three-dimensional cone beam computerized tomography in dentistry. Dent Today 25:130-135, 2006
6. Kau CH, Richmond S, Incrapera A, et al: Three-dimensional surface acquisition systems for the study of facial
morphology and their application to maxillofacial surgery. Int J Med Robot 3:97-110, 2007
7. Mah J, Hatcher D: Current status and future needs in
craniofacial imaging. Orthod Craniofac Res 6:10-16; discussion: 179-182, 2003
8. Sukovic P: Cone beam computed tomography in craniofacial imaging. Orthod Craniofac Res 6:31-36; discussion: 179-182, 2003
9. Mah JK, Danforth RA, Bumann A, et al: Radiation absorbed in maxillofacial imaging with a new dental computed tomography device. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 96:508-513, 2003
10. Ludlow JB, Ivanovic M: Comparative dosimetry of dental
CBCT devices and 64-slice CT for oral and maxillofacial
radiology. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 106:930-938, 2008
11. Lagravere MO, Carey J, Toogood RW, et al: Three-dimensional accuracy of measurements made with software on cone-beam computed tomography images. Am J
Orthod Dentofac Orthop 134:112-116, 2008
12. Kau CH, Pan P, Gallerano RL, et al: A novel 3D classification system for canine impactionsthe KPG index.
Int J Med Robot 5:291-296, 2009
13. Incrapera AK, Kau CH, English JD, et al: Soft tissue
images from cephalograms compared with those from a
3D Surface Acquisition System. Angle Orthod 80:58-64,
2010
14. Chenin DL, Chenin DA, Chenin ST, et al: Dynamic
cone-beam computed tomography in orthodontic treatment. J Clin Orthod 43:507-512, 2009
15. De Vos W, Casselman J, Swennen GR: Cone-beam computerized tomography (CBCT) imaging of the oral and
maxillofacial region: a systematic review of the literature.
Int J Oral Maxillofac Surg 38:609-625, 2009

16. Chiu CS, Clark RK: Reproducibility of natural head position. J Dent 19:130-131, 1991
17. Kau CH, Richmond S, Zhurov AI, et al: Reliability of
measuring facial morphology using a 3-dimensional laser scanning system. Am J Orthod Dentofac Orthop
128:424-430, 2005
18. Kau CH, Zhurov AI, Bibb R, et al: The investigation of
the changing facial appearance of identical twins employing a three-dimensional laser imaging system. Orthod Craniofac Res 8:85-90, 2005
19. Kau CH, Bozic M, English J, et al: Cone-beam computed
tomography of the maxillofacial region-an update. Int
J Med Robot 5:366-380, 2009
20. Danforth RA, Dus I, Mah J: Three-D volume imaging for
dentistry: a new dimension. J Calif Dent Assoc 31:817823, 2003
21. Ludlow JB, Davies-Ludlow LE, Brooks SL, et al: Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G and i-CAT. Dentomaxillofac Radiol 35:219-226, 2006
22. Bjork A: Prediction of mandibular growth rotation. Am J
Orthod 55:585-599, 1969
23. Bjork A, Skieller V, Linde-Hansen T: Variations in the
growth pattern of the human mandible: Longitudinal
Radiographic Study by the implant method. J Dent Res
42:400-411, 1963
24. Kau CH, Richmond S: Three-dimensional analysis of
facial morphology surface changes in untreated children
from 12 to 14 years of age. Am J Orthod Dentofac
Orthop 134:751-760, 2008
25. Kau CH, Zhurov A, Scheer R, et al: The feasibility of
measuring three-dimensional facial morphology in children. Orthod Craniofac Res 7:198-204, 2004
26. Kau CH, Zhurov A, Richmond S, et al: The 3-dimensional construction of the average 11 year old child face:
a clinical evaluation and application. J Oral Maxillofac
Surg 64:1086-1092, 2006
27. Kamel SG, Kau CH, Wong ME, et al: The role of cone
beam CT in the evaluation and management of a family
with Gardners syndrome. J Craniomaxillofac Surg 37:
461-468, 2009
28. Bo IcM, Kau CH, Richmond S, et al: Facial morphology
of Slovenian and Welsh white populations using 3-dimensional imaging. Angle Orthod 79:640-645, 2009
29. Seager DC, Kau CH, English JD, et al: Facial morphologies of an adult Egyptian population and an adult Houstonian White population compared using 3D imaging.
Angle Orthod 79:991-999, 2009
30. Berkowitz S, Cuzzi J: Biosterometric analysis of surgically
corrected abnormal faces. Am J Orthod 72:526-538,
1977
31. McCance AM, Moss JP, Fright WR, et al: Three-dimensional analysis techniquespart. 2: Laser scanning: a
quantitative three-dimensional soft-tissue analysis using
a color-coding system. Cleft Palate Craniofac J 34:46-51,
1997
32. Hajeer MY, Ayoub AF, Millett DT: Three-dimensional
assessment of facial soft-tissue asymmetry before and
after orthognathic surgery. Br J Oral Maxillofac Surg
42:396-404, 2004

Future of Orthodontic Diagnostic Records

33. Xia J, Samman N, Yeung RW, et al: Computer-assisted

three-dimensional surgical planning and simulation. 3D
soft tissue planning and prediction. Int J Oral Maxillofac
Surg 29:250-258, 2000
34. Marumulla R, Hassfeld S, Luth T, et al: Laser-scan-based
navigation in cranio-maxillofacial surgery. J Craniomaxillofac Surg 31:267-277, 2003
35. Harrison JA, Nixon MA, Fright WR, et al: Use of hand held
laser scanning in the assessment of facial swelling: a preliminary study. Br J Oral Maxillofac Surg 42:8-17, 2004
36. Hajeer MY, Mao Z, Millett DT, et al: A new three-dimensional
method of assessing facial volumetric changes after orthognathic surgery. Cleft Palate Craniofac J 42:113-120, 2005
37. Yip E, Smith A, Yoshino M: Volumetric evaluation of

38.

39.

40.

41.

45

facial swelling utilizing a 3-D range camera. Int J Oral

Maxillofac Surg 33:179-182, 2004
Marmulla R, Hassfeld S, Luth T, et al: Laser-scan-based
navigation in cranio-maxillofacial surgery. J Craniomaxillofac Surg 31:267-277, 2003
Marmulla R, Luth T, Muhling J, et al: Markerless laser
registration in image-guided oral and maxillofacial surgery. J Oral Maxillofac Surg 62:845-851, 2004
Kau CH, Littlefield J, Rainy N, et al: Evaluation of CBCT
digital models and traditional models using the littles
index. Angle Orthod 80:435-439, 2010
Brix G, Nekolla EA, Nosske D, et al: Risks and safety
aspects related to PET/MR examinations. Eur J Nucl
Med Mol Imaging 36:S131-S138, 2009