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