ORIGINAL ARTICLE

Accuracy and reliability of cone-beam computed

tomography measurements: Influence of head
orientation
Amr Ragab El-Beialy,a Mona Salah Fayed,b Ahmed Mohammed El-Bialy,c and Yehya A. Mostafad
Cairo, Egypt

Introduction: The purpose of this research is to determine the accuracy and reliability of measurements
obtained from 3-dimensional (3D) cone-beam computed tomography (CBCT) for different head orientations.
Methods: Stainless steel wires were fixed to a dry skull at different places. The skull was scanned by using
CBCT in the centered and 5 other positions. Intraobserver and interobserver reliability tests were performed
by using 6 landmarks identified on the virtual 3D skulls by 2 operators. Two methods were used to determine
the accuracy of measurements on the virtual 3D skull scanned in different positions. In the first method, 12 linear
distances were compared on the physical skull and the 3D virtual skull in the centered and the other scanning
positions. In the second method, registration of each of the 5 positions on the centered position was done
separately, and coordinates of 11 landmarks were identified in each position and compared with the centered
position. Data gathered from the 2 methods were compared statistically. Results: Concordance correlation
and Pearson correlation coefficients values were almost 0.9999 in all the comparisons denoting: (1) high intra-
observer and interobserver reliability; (2) very high concordance between the physical skull and the CBCT
centered-position measurements; (3) very high concordance between measurements of the centered position
in relation to those obtained from the different skull positions; and (4) registration of the skulls in the different
positions showed high concordance, with the highest values between the centered and off-centered
positions, and the lowest with the complex position. Conclusions: Accuracy and reliability of CBCT measure-
ments are not affected by changing the skull orientation. Thus, the upper-lip and chin rests should not be
considered absolute requirements during CBCT imaging if a stable head position is ensured. (Am J Orthod
Dentofacial Orthop 2011;140:157-65)

I
nterest in 3-dimensional (3D) imaging devices has
grown over the last decade. Orthodontists are begin-
ning to appreciate the advantages of the third dimen-
sion in clinical diagnosis, treatment planning, and patient
education.1 Cone-beam computed tomography (CBCT) is
From Cairo University, Cairo, Egypt.
a
Associate lecturer, Department of Orthodontics and Dentofacial Orthopedics,
Faculty of Oral and Dental Medicine.
b
Lecturer, Department of Orthodontics and Dentofacial Orthopedics, Faculty of
Oral and Dental Medicine.
c
Associate professor, Systems and Biomedical Engineering Department, Faculty
of Engineering.
d
Professor, Department of Orthodontics and Dentofacial Orthopedics, Faculty of
Oral and Dental Medicine.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Yehya A. Mostafa, Department of Orthodontics and Dento-
facial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, 52 Arab
League St, Mohandesseen, Giza, Egypt; e-mail, mangoury@usa.net.
Submitted, September 2009; revised and accepted, March 2010.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.03.030
being more frequently applied for orthodontic assessment.
CBCT provides immediate and accurate 2-dimensional and
3D radiographic images of an anatomic structure, limited
only by the system’s innate or selected field of view. For
machines with large fields of view (eg, the Galileos CBCT
machine; Sirona, Bensheim, Germany), the data acquired
by the scan can be used to reconstruct approximations
of 2-dimensional cephalograms and also for a growing
number of 3D analyses.2 CBCT has been used now for
several years. Its applications in dentistry have already
been determined by its performance, low cost, and low
radiation dose.3-8 However, accuracy for various uses has
not yet been verified.
Recent studies have shown some controversies con-
cerning the accuracy of the measurements obtained
from CBCT. Lascala et al9 found that, although the
CBCT image underestimated the real distances between
skull sites, the differences were significant only for the
skull base; therefore, it was reliable for linear evaluation
measurements of other structures more closely associ-
ated with dental and maxillofacial imaging.
157
158
Fig 1. CBCT output with upper lip rest.
On the other hand, Lagravere et al10 evaluated the
accuracy of measurements made on 9-in and 12-in
CBCT images compared with measurements made on
a coordinate measuring machine; they found no signifi-
cant statistical differences between the linear and angular
measurements from the coordinate measuring machine
and the NewTom 3G (Aperio Services, Verona, Italy)
images. Hence, they concluded that the NewTom 3G
produces a 1-to-1 image-to-reality ratio.
In another study, Periago et al11 compared the reli-
ability and accuracy of linear measurements made on
3D volumetric reconstructions generated from CBCT
data sets to direct measurements made on ex-vivo skulls.
They found that, for two thirds of the dimensions, the
CBCT measurements were statistically significantly dif-
ferent from the actual measurements. However, they
commented that, after analyzing the absolute and per-
centage differences, this statistical significance probably
did not translate into clinical relevance.
Recently, 2 studies investigated the effects of chang-
ing the position of the head in the CBCT machine on the
accuracy of the measurements obtained. In the study by
Hassan et al,12 8 dry skulls were scanned twice with the
NewTom 3G CBCT in ideal and rotated positions. The
findings indicated that measurements based on 3D
CBCT surface images were accurate, and small variations
in the patient’s head position did not influence
measurement accuracy. In the same context, Berco
et al13 investigated the accuracy and reliability of
CBCT measurements compared with the true measure-
ments of a dry skull in 2 orientations: with the Frankfort
horizontal plane parallel to the floor, and with the
Frankfort horizontal plane aligned 45 to the floor. No
statistically significant differences were observed
between the measurements.
Although several attempts were made to verify the
accuracy of CBCT, the verdict is not conclusive. In
August 2011  Vol 140  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
El-Beialy et al
Fig 2. Stainless steel wires glued on the skull.
addition, the accuracy with respect to the orientation
of the patient’s head without head-positioning devices
is still an issue of concern.
CBCT machines have integrated head-positioning
devices, such as the upper lip rest and the chin rest.
Despite their importance to ensure stabilization as
recommended by the manufacturers, they cause oblitera-
tion and distortion of the patient’s facial soft tissues
(Fig 1). The importance of visualization of the tissues of
the lower third of the face in orthodontics should not be
ignored. Thus, the aim of this study was to investigate
the accuracy and reliability of CBCT measurements of var-
ious head orientations without upper-lip and chin rests.
MATERIAL AND METHODS
A dry skull was fixed on a tripod with a plumber mix-
ture, which hardens 10 minutes after mixing the base and
the catalyst. A stainless steel orthodontic wire, 0.7 mm in
diameter, was cut into various lengths, arranged in 3 forms
(horizontal, vertical, and T-shaped), and fixed bilaterally
on the skull with permanent glue (Fig 2). The skull was
then scanned by using the Galileos CBCT machine with
a standard scanning program (85 kV, 21 mA, 200 slices)
in 6 positions without lip and chin rests: position 1 (cen-
tered), the skull was centered in the focal trough according
to the manufacturer’s instructions (Fig 3, A); position 2
El-Beialy et al
Fig 3. A, Skull centered in the CBCT machine; B, skull with anteroposterior tilt; C, skull with complex
tilt; D, skull in off-centered position.
(posterior tilt), the skull was tilted posteriorly from the
centered position (Fig 3, B); position 3 (lateral tilt), the
skull was tilted laterally to the right of the observer; posi-
tion 4 (torsion), the skull was rotated in a torsion pattern
(rotation to the left of the observer around its long axis,
which passes through the foramen magnum); position 5
(complex), the skull was tilted in a complex manner
(combination of anteroposterior, lateral, and torsion
movements) (Fig 3, C); and position 6 (off centered), the
skull in the centered orientation (position 1) was moved
to the right of the observer (Fig 3, D).
To calculate the changes in the skull position from
position 1, first the skull in the centered orientation
was altered to produce positions 2 through 6. Then the
software calculated the precise amounts of spatial
movement for the 5 positions (positions 2-6) (Table I).14
The 3D volumes of the virtual skulls were generated
by compiling the computed tomography slices of the
different skull positions by using the Mimics software
(version 8.1; Materialise, Leuven, Belgium; Fig 4). The
threshold of the 3D volume was adjusted to subtract
the bone and visualize the wires glued on the skull
(Fig 5). The minimum and maximum thresholds were
2250 and 3071 Hounsfield units, respectively, which
were applied to the 6 skull views.
The intraobserver and interobserver reliability tests
were performed to investigate the errors in the measure-
ment method used in this study. Six well-defined
American Journal of Orthodontics and Dentofacial Orthopedics
159
landmarks (x, y, and z coordinates) were identified on
the ends of the metal wires glued on the skull on each
of the 6 skull views. Using the 3D visualization software,
the landmarks were identified by an operator (A.R.E.-B.)
and again 2 weeks later.14 The coordinates of the land-
marks were recorded and compared to determine the in-
traobserver error. The same landmarks were identified by
another operator (M.S.F.) and the coordinates compared
with those of the first operator to investigate the
interobserver error.
The life-sized output of the CBCT was investigated.
The measurements of the wire lengths on the centered
virtual skull position (Fig 6) were compared with the
true (physical) lengths of the wires glued on the skull
(gold standard).
The null hypothesis of this study was that there is no
difference in the output of the CBCT measurements
when imaging the skull in the different orientations.
Investigation of the null hypothesis was carried out us-
ing 2 methods; the first by comparing 12 linear distances
between the same landmarks on the 6 virtual skulls. The
second through registering (3D superimposition) each
virtual skull (positions 2-5) on the centered virtual skull
(position 1). This is done by assigning 3 well-defined
points on the centered virtual skull position and locating
3 identical points on each of the other virtual skulls. Reg-
istration of each pair of virtual skulls on these 3 identical
landmarks was thus performed.14
August 2011  Vol 140  Issue 2
160 El-Beialy et al

Table I. Amount of transformation (translation and

rotation) in the x, y, and z directions, from the centered
to the other skull positions
x y z
Anteroposterior
Translation (mm) 1.40169 6.98926 17.575
Rotation ( ) 16.6091 0.55455 1.91792
Lateral
Translation (mm) 20.3651 14.3071 15.8192
Rotation ( ) 10.576 18.6867 1.30573
Torsion
Translation (mm) 26.1911 33.6892 11.871
Rotation ( ) 0.774023 3.17285 21.304
Complex
Translation (mm) 3.46304 15.4782 38.8496
Rotation ( ) 11.1493 20.8478 20.704
Off-centered
Translation (mm) 16.9756 1.97839 1.76982
Rotation ( ) 1.00116 0.03873 1.69138

A negative translation sign denotes translation towards lesser values Fig 4. Three-dimensional volume of the skull.
along the axis. A negative rotation sign denotes rotation in the
clockwise direction.

The registration method used was based on a tech-

nique known as iterative closest point. The iterative
closest point algorithm is a standard solution to the
alignment problem of free-form surfaces. Its popularity
can be accredited to its versatility; it can be used for
point sets, implicitly and explicitly defined curves and
surfaces, line segment sets (polylines), triangle sets
(faceted surfaces), and volumes. This technique is
characterized by high computational speed and ease of
implementation. Also, it was proved to converge mono-
tonically to the nearest local minimum of a mean-square
distance metric. This method handles the full 6 degrees
of freedom of rotation and translation.
This iterative algorithm has 3 basic steps: (1) pair each
point of the first object to the closest point in the second
object, (2) compute the transformation that minimizes
the mean square error between the paired points with re-
spect to the 6 rotations and translation parameters, and
(3) apply the transformation to data-set points of the first Fig 5. Adjustment of the threshold for the subtraction of
object and update the mean square error. bone.
Afterward, coordinates of the 11 landmarks identified
on each pair of registered skulls were compared. Any dis- mean differences and standard deviations of the intraob-
crepancy between the coordinates would reflect distortion server and interobserver measurements were calculated.
of the CBCT output with variable skull orientations (Figs 7, To quantify the sizes of the differences and assess
A and B, and 8). agreement between measurements, the limit of agreement
(LOA) was used.15 LOA is calculated as mean difference 62
Statistical analysis SD. Concordance correlation coefficients (CCC) and Pear-
Descriptive statistics were used to measure the means son correlation coefficients (Pearson r) were used to test
and standard deviations of the x, y, and z coordinates of concordance, which is the correlation with equivalency of
each of the 6 landmarks in the 6 skull positions. The the measurements (intraobserver and interobserver) as

August 2011  Vol 140  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
El-Beialy et al 161

Fig 6. Measurements on the centered 3D skull.

Fig 7. A, Unregistered centered skull on torsion skull; B, registered centered skull on torsion skull;
C, unregistered centered skull on complex skull; D, registered centered skull on complex skull.

well as between physical measurements from the skull and the centered position compared with the other 5 posi-
those measured on the skull in the centered position. tions and to measure concordance between coordinates
The same statistical test was used to measure the taken at registration of the centered and the other
concordance between measurements obtained from skull positions. The sample concordance correlation

American Journal of Orthodontics and Dentofacial Orthopedics August 2011  Vol 140  Issue 2
162 El-Beialy et al

Fig 8. Coordinates (red and blue) of the same landmark identified on registered centered-complex 3D
skulls.

Table II. LOA, CCC, and Pearson r to test the concor-

0.999919; these reflect high concordance between the
dance of the skulls compared with centered CBCT measurements (Table II).
measurements The comparison of CBCT linear measurements from
the centered position with those from the other 5 positions
Mean difference between skull and centered CBCT 0.945
measurements (mm) showed high concordance between all measurements
SD 1.172 from the different skull positions in relation to those of
Upper LOA (mean 12 SD) 3.289 the centered position as follows: for the centered-
Lower LOA (mean –2 SD) 1.4 anteroposterior concordance, CCC was 0.999796 and
Range 4.689
Pearson r was 0.999871; for the centered-lateral concor-
Relative range 7.76%
CCC 0.999293 dance, CCC was 0.999702 and Pearson r was 0.999912;
Upper confidence level 0.99966 for the centered-torsion concordance, CCC was
Lower confidence level 0.998532 0.999875 and Pearson r was 0.999920; for the
Pearson r 0.999919 centered-complex concordance, CCC was 0.999618 and
Pearson r was 0.999777, and for the centered–off-
coefficient was proposed by Lin16,17 for assessment of centered concordance, CCC was 0.999484 and Pearson r
concordance between alternative methods. It can was 0.999710 (Table III).
range from 1 to 11 as does the Pearson r. A value The comparison between the coordinates of the 12
of 11 denotes perfect correlation. Hence, the nearer landmarks on the centered position CBCT and those
the value of the CCC and the Pearson r to 11, the on the 5 other positions on applying the registration
higher the concordance between the measurements in technique showed high concordance of the coordinates
comparison and vice versa. on the centered position with those of the other
positions, with the highest concordance with the off-
RESULTS centered position (CCC, 0.99943; Pearson r, 0.999951)
For intraobserver and interobserver reliability, the and the lowest with the complex position (CCC,
CCC and Pearson r coefficients were between 0.999952 0.986318; Pearson r, 0.988006) (Table IV).
and 0.9999896 for intraobserver measurements, and
between 0.999918 and 0.9999882 for interobserver DISCUSSION
measurements in the identification of the selected land- Orthodontists place significant emphasis on modifi-
marks on the CBCT in the x, y, and z coordinates; these cation of growth, in addition to correcting dental
reflect high intraobserver and interobserver reliabilities. malrelationships. Successful orthodontic and surgical
In the comparison of the physical measurements treatments of such anomalies require accurate and
from the skull with those on the CBCT in the centered reliable imaging of the craniofacial complex.18 CBCT
position, CCC was 0.999293, and Pearson r was was developed in the 1990s as an evolutionary process

August 2011  Vol 140  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
El-Beialy et al 163

Table III. LOA, CCC, and Pearson r to test the concordance of the CBCT measurements of the different skull positions
compared with the centered position
Centered- Centered–
Skull positions in comparison anteroposterior Centered-lateral Centered- torsion Centered- complex off-centered
Absolute difference in measurements (mm) 0.5425 0.6191 0.4059 0.7902 0.8723
Mean difference in measurements (mm) 0.2677 0.5543 0.2279 0.3383 0.5646
SD 0.7691 0.8033 0.5924 1.0642 1.1629
Upper LOA (mean 12 SD) 1.271 1.052 0.957 1.790 1.761
Lower LOA (mean –2 SD) 1.806 2.161 1.413 2.467 2.890
Range 3.077 3.213 2.370 4.257 4.651
Relative range 5.12% 5.33% 3.94% 7.08% 7.72%
CCC 0.999796 0.999702 0.999875 0.999618 0.999484
Upper confidence level 0.999920 0.999871 0.999952 0.999845 0.999800
Lower confidence level 0.999474 0.999312 0.999673 0.999058 0.998669
Pearson r 0.999871 0.999912 0.999920 0.999777 0.999710

Table IV. LOA, CCC, and Pearson r to test the concordance of coordinates on the different skull positions compared
with those of the centered position
Centered- Centered–
Skull positions in comparison anteroposterior Centered-lateral Centered- torsion Centered- complex Off-centered
Absolute difference in coordinates 0.5050 0.4913 0.5053 3.6866 0.2534
Mean difference in coordinates 0.0372 0.3220 0.2093 1.6464 0.0384
SD 0.6666 0.5592 0.7322 4.9664 0.3561
Upper LOA (mean 12 SD) 1.296 0.796 1.255 11.579 0.751
Lower LOA (mean –2 SD) 1.370 1.440 1.674 8.286 0.674
Range 2.667 2.237 2.929 19.865 1.425
Relative range 3.62% 3.06% 4% 27.25% 1.83%
CCC 0.999782 0.999786 0.999692 0.986318 0.999943
Upper confidence level 0.999879 0.999879 0.999829 0.992331 0.999967
Lower confidence level 0.999607 0.999620 0.999446 0.9995651 0.999901
Pearson r 0.999783 0.999846 0.999719 0.988006 0.999951

resulting from the demand for 3D information
obtained by conventional computed tomography scans.
Custom-built craniomaxillofacial CBCTs started to
appear in the market over the last decade, and various
applications to facial and dental environments are
being established.11
Debates are found in the literature about the
accuracy of the measurements obtained from CBCT
scans. Some claim that there are underestimations of
the measurements,9 and others claim that the measure-
ments have a 1:1 ratio to the real size measurements.10
The purpose of this study was to investigate the accuracy
and reliability of measurements obtained from 3D CBCT
for different head orientations.
In this study, a dry skull was used, with glued radi-
opaque markers in the form of stainless steel wires to
act as sharp, well-defined landmarks for measurements.
Such sharp ends were used to eliminate the difference in
perception of definitions of skeletal landmarks. Dry
skulls are used to validate new craniofacial imaging
modalities.9,12,13,19-21 Direct measurements on the
skull are used as the gold standard for comparison
purposes. Unlike the studies of Hassan et al12 and Berco
et al13 in which the skulls were tilted 15 and 45 later-
ally, respectively, we chose to change the orientation of
the skull in the scanner to 5 positions in addition to the
centered position dictated by the manufacturer. Since, in
a clinical situation, a minor patient movement in the
focal trough of the CBCT is unplanned, the exact calcu-
lation of the different skull positions was done in
a reverse manner. First, the skull orientation in the
CBCT was altered, and then the exact translation and
rotation values for the 5 positions (positions 2-6) were
extracted from the software used for measuring on the
3D volumes of the skulls.14
In this study, the statistical analysis was selected for
comparing the equivalency, agreement, and correlation
of the intraobserver and interobserver concordance, reg-
istration coordinates, and linear measurements applied
in the first method. The LOA was used as a sensitive
test for quantification of differences between measure-
ments; then the CCC and the Pearson r were applied;

American Journal of Orthodontics and Dentofacial Orthopedics August 2011  Vol 140  Issue 2
164
these are specific for equivalence studies concerned with
clinical measurements.15-17 Periago et al11 used the
paired t test to conduct a similar analysis, and the results
showed significant differences between all measure-
ments; the authors described these results as misleading,
not reflecting clinical relevance.
Unlike the aforementioned studies, the landmarks we
used were identified on the wires, which were easily and
clearly defined on both the skull and the CBCT. We
focused on the repeated measurements taken on the
same skull, whereas other studies such as that of Hilgers
et al20 compared measurements obtained from 50 skulls,
and Hassan et al12 used 8 skulls. If many skulls are used to
draw a mean for a specific measurement, it follows that
the variability of the mean will be higher than that
from repeated measurements on 1 skull; hence, the latter
technique is more sensitive to the smallest differences.
To perform an accurate assessment of the accuracy
and reliability of CBCT measurements for different skull
orientations, 2 methods were chosen. The first method is
the one used in most other studies, with landmarks iden-
tified and linear measurements taken between these
landmarks. Almost perfect concordance was found
between the physical measurements obtained from the
wires on the skull with those of the centered position;
this allowed us to use the centered position as the base
of comparison with the other positions.
The same extremely high concordance was found be-
tween the measurements from the 5 positions compared
with the centered position. These results agreed with
those of Hassan et al12 and Berco et al,13 even though
the tilt we used was not only in the lateral direction as
described by the 2 previous studies, but also in different
directions.
After performing the registrations (Fig 7, A and B), 11
landmarks were identified and their coordinates recorded
on each of the superimposed skulls. Extremely high
concordance was found between the coordinates of the
different positions compared with the centered position,
except for the complex position. This can be explained
because this position had the greatest spatial changes.
On the other hand, the most correlated coordinates
were those of the centered and off-centered positions,
because the off-centered position represented the small-
est shift of all the other positions.
Thus, if the patient’s head is stable during scanning,
the spatial position of the head in the focal trough of the
CBCT will not affect the outcome. When patient head
movement is expected—eg, during scanning a small
child—we suggest using the forehead rest as the only
head-positioning device during scanning.
August 2011  Vol 140  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
El-Beialy et al
CONCLUSIONS
Accuracy and reliability of CBCT measurements are not
affected by changing the skull orientation. Furthermore,
upper-lip and chin rests should not be considered an ab-
solute requirement during CBCT imaging if a stable head
position is ensured in the focal trough. The authors
address the CBCT manufacturers to add an occipital
head rest away from the field of interest. This will add
a mean for stabilization of the head without obliterating
the tissues of the lower facial third.
REFERENCES
1. Kau C, Richmond S, Palomo J, Hans M. Current products and
practice. Three dimensional cone beam computerized tomography
in orthodontics. J Orthod 2005;32:282-93.
2. Farman A, Scarfe W. The basics of maxillofacial cone beam
computed tomography. Semin Orthod 2009;15:2-13.
3. Mah JK, Danforth RA, Bumann A, Hatcher D. Radiation absorbed
in maxillofacial imaging with a new dental computed tomography
device. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:
508-13.
4. Bianchi S, Anglesio S, Castellano S, Rizzi L, Ragona R. Absorbed
doses and risk in implant planning: comparison between spiral CT
and cone-beam CT. Dentomaxillofac Radiol 2003;30(1:16.6):S28.
5. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two
extraoral direct digital imaging devices: NewTom cone beam CT
and Orthophos Plus DS panoramic unit. Dentomaxillofac Radiol
2003;32:229-43.
6. Sukovic P. Cone beam computed tomography in craniofacial
imaging. Orthod Craniofac Res 2003;6(Supp 1):31-6.
7. Hashimoto K, Arai Y, Iwai K, Araki M, Kawashima S, Terakado M. A
comparison of a new limited cone beam computed tomography
machine for dental use with a multidetector row helical CT
machine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2003;95:371-7.
8. Ziegler CM, Woertcher R, Brief J, Hassfeld S. Clinical indications for
digital volume tomography in oral and maxillofacial surgery.
Dentomaxillofac Radiol 2002;31:126-30.
9. Lascala C, Panella J, Marques M. Analysis of the accuracy of linear
measurements obtained by cone beam computed tomography
(CBCT-NewTom). Dentomaxillofac Radiol 2004;33:291-4.
10. Lagravere M, Carey J, Toogood R, Major P. Three-dimensional
accuracy of measurements made with software on cone-beam
computed tomography images. Am J Orthod Dentofacial Orthop
2008;134:112-6.
11. Periago D, Scarfe W, Moshiri M, Scheetz J, Silveria A, Farman A.
Linear accuracy and reliability of cone beam CT derived 3-dimen-
sional images constructed using an orthodontic volumetric
rendering program. Angle Orthod 2008;78:387-95.
12. Hassan B, Setelt P, Sanderink G. Accuracy of three-dimensional
measurements obtained from cone beam computed tomography
surface-rendered images for cephalometric analysis: influence of
patient scanning position. Eur J Orthod 2008;23:1-6.
13. Berco M, Rigali PH Jr, Miner MR, DeLuca S, Anderson NK,
et al. Accuracy and reliability of linear cephalometric measure-
ments from cone-beam computed tomography scans of a dry
human skull. Am J Orthod Dentofacial Orthop 2009;136:
17.e1-9.
El-Beialy et al
14. El-Beialy AR, Abou-El-Ezz AM, Attia KH, El-Bialy AM, Mostafa YA.
Loss of anchorage of miniscrews: a 3-dimensional assessment. Am
J Orthod Dentofacial Orthop 2009;136:700-7.
15. Bland J, Altman D. Statistical methods for assessing agreement be-
tween two methods of clinical measurement. Lancet 1986;8:307-10.
16. Lin LI. A concordance correlation coefficient to evaluate reproduc-
ibility. Biometrics 1989;45:255-68.
17. Lin LI. A note on the concordance correlation coefficient. Biomet-
rics 2000;56:324-5.
18. Valiathan A, Dhar S, Verma N. 3D CT imaging in orthodontics:
adding a new dimension to diagnosis and treatment planning.
Trends Biomater Artif Organs 2008;21:116-20.
American Journal of Orthodontics and Dentofacial Orthopedics
165
19. Hilgers ML, Scarfe WC, Scheetz JP, Farman AG. Accuracy of linear
temporomandibular joint measurements with cone beam com-
puted tomography and digital radiography. Am J Orthod Dentofa-
cial Orthop 2005;128:803-11.
20. Calvalcanti MG, Haller JW, Vannier MW. Three dimensional com-
puted tomography landmark measurement in craniofacial surgical
planning: experimental validation in vitro. J Oral Maxillofac Surg
1999;57:690-4.
21. Moshiri M, Scarfe W, Hilgers M, Scheetz JP, Silveira AM, Farman AG.
Accuracy of linear measurements from imaging plate and lateral
cephalometric images derived from cone-beam computed tomogra-
phy. Am J Orthod Dentofacial Orthop 2007;132:550-60.
August 2011  Vol 140  Issue 2