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                   ORTHODONTICS
                   ARE DENTAL MEASUREMENTS TAKEN ON PLASTER CASTS COMPARABLE TO THOSE
Original Article
                   TAKEN FROM CBCT IMAGES AND LASER SCANNED SURFACES?
                   Luca Pisoni1a, Marina Codari2b, Simone Galli1c, Francesca M.E. Rusconi1d, Gianluca Martino Tartaglia1e, Valentina Pucciarelli1f,
                   Chiarella Sforza1g*
                   1
                    LAFAS, Laboratory of Functional Anatomy of the Stomatognathic System, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
                   2
                    Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese, 20097 Milan, Italy.

                   a,e
                      DDS, PhD
                   b
                     MSBE, PhD
                   c
                     CDT
                   d
                     DDS
                   f
                    MBiothec, PhD
                   g
                     MD, PhD, Head

                    ABSTRACT                                                DOI: 10.25241/stomaeduj.2018.5(1).art.4
                   Introduction: Intraoral scanning techniques, laser scans and cone-beam computed                                                     OPEN ACCESS This is an
                   tomography (CBCT) are becoming widely diffused in dental practice. These instruments                                                Open Access article under the CC
                                                                                                                                                       BY-NC 4.0 license.
                   can replace dental plaster casts with digital models; recent investigations have found that
                                                                                                                                                       Peer-Reviewed Article
                   measurements taken on digital models do not differ clinically from those obtained on
                   CBCT scans and physical models, but only intra-examiner reliability has been assessed. In                                      Citation: Pisoni L, Codari M, Galli S,
                                                                                                                                                  Rusconi FME, Tartaglia GM, Pucciarelli
                   the current study we tested both intra- and inter-examiner variations, together with inter-                                    V, Sforza C. Are dental measurements
                   techniques reliability.                                                                                                        taken on plaster casts comparable to
                                                                                                                                                  those taken from CBCT images and
                   Methodology: Data from six adult subjects were retrospectively obtained. Twelve dental                                         laser scanned surfaces? Stoma Edu J.
                                                                                                                                                  2018;5(1):38-42.
                   distances were measured on dental plaster casts using a digital calliper; on digital 3D CBCT
                   images using inVivoDental software (Anatomage, San Jose, CA); and on laser scanned                                             Academic Editor: Lidia Boboc, DDS,
                                                                                                                                                  PhD, Associate Professor, “Carol Davila”
                   surfaces using Mirror Vectra Software (Canfield Scientific, Fairfield, NJ). Two different                                      University of Medicine and Pharmacy
                   operators performed all measurements twice. Bland-Altman analysis, Kruskal-Wallis and                                          Bucharest, Romania

                   Wilcoxon tests were used for comparisons.                                                                                      Received: December 23, 2017
                   Results: The intra- and inter-operator biases range was 0-0.34 mm. The reproducibility range                                   Revised: February 09, 2018
                                                                                                                                                  Acccepted: March 01, 2018
                   was 72-99%. The three different techniques gave very similar measurements, with biases                                         Published: March 03, 2018
                   between ±0.1 mm. Reproducibility ranged between 90 and 100%; the best reproducibility                                          *Corresponding author: Professor
                   coefficients were found between plaster and digital casts, and only three differences were                                     Chiarella Sforza, MD, PhD, Head
                                                                                                                                                  Department of Biomedical Sciences
                   larger than 0.5 mm. Calliper measurements slightly overestimated digital casts values. Only                                    for Health, University of Milan, Milan,
                   the mesiodistal distance of tooth 24 (p=0.002) was significantly different among techniques.                                   Italyvia Mangiagalli 31, I-20133 Milano,
                                                                                                                                                  Italy Tel: +39 – 02 503 15385, Fax:
                   Conclusion: Measurements on digital dental models and CBCT reconstructions of the dental                                       +39 – 02 503 15387, e-mail: chiarella.
                   arches seem clinically reliable as direct calliper measurements. The inter- and intra-operator                                 sforza@unimi.it

                   reliabilities were acceptable, some more care may be needed for CBCT measurements.                                             Copyright: © 2018 the Editorial Coun-
                   Keywords: teeth, laser scan, cone beam computerised tomography.                                                                cil for the Stomatology Edu Journal.



                   1. Introduction                                                               skulls with conventional digital callipers [16, 17].
                   New technologies like scanning techniques, cone-                              Safety, accuracy and reliability of measurements taken
                   beam computerised tomography (CBCT) and three                                 with new instruments must be evaluated and compared
                   dimensional imaging are becoming more and more                                with those obtained with traditional methods also for
                   used in all branches of dental practice (conservative,                        dental landmarks: data obtained from both the digital
                   prosthodontics, surgery and orthodontics). Among the                          and traditional plaster casts models must match in
                   other applications, these devices can replace dental                          order to allow using the new technologies in clinical
                   plaster casts with digital models possessing several                          practice [2, 8, 18].
                   advantages: easy storage, no necessary physical space,                        In general, recent investigations found that
                   no damages during handling, and easy data share with                          measurements taken on digital models do not differ
                   other professionals [1-9].                                                    clinically from those obtained on CBCT scans and
                   CBCT, in particular, gives a 3D representation of the                         physical models [4, 5]. Unfortunately, while reporting
                   cranio-facial and dental structures and has already                           intra-examiner reliability, no inter-examiner variations
                   several indications in clinical routine: oral and                             were presented [6-8]. Indeed, the assessment of inter-
                   maxillofacial surgery (orthognathic surgery, treatment of                     operator variations seems to be of relevance in the
                   traumas and malignancies, nerve tracing in cases of third                     current scenario where dental technicians often work
                   molar extraction and implant placement), endodontics                          in centralised locations at distance from clinical offices,
                   (root fracture detection), orthodontics (diagnosis and                        and several of them may be involved in the evaluation
                   treatment planning) [6, 10-15]. In this last field, several                   of the same dental reproductions.
                   studies have successfully compared the accuracy of                            In the current study, we compared measurements
                   craniofacial measurements taken using landmarks                               taken on digital models obtained from CBCT images
                   identified on CBCT scans with those taken directly on                         and laser scanned surfaces with direct measurements



   38                                                                           Stoma Edu J. 2018;5(1): 38-42                      http://www.stomaeduj.com
                                 ARE DENTAL MEASUREMENTS TAKEN ON PLASTER CASTS COMPARABLE TO THOSE
                                                 TAKEN FROM CBCT IMAGES AND LASER SCANNED SURFACES?


obtained on dental plaster casts. Both intra- and inter-




                                                                                                                                                 Original Article
operator reliabilities were assessed.


2. Material and methods
Data from six adult Caucasian subjects with full
dentition, no implant surgery, dental fillings, prostheses
or caries that could affect the morphology of teeth
were obtained. The absence of implants and metal
fillings was selected as inclusion criterion to reduce
the presence of metal artefacts that can alter the
measurement process.
All patients were retrospectively selected from a clinical
database and underwent CBCT examination for clinical
reasons uncorrelated with this study. Their plaster casts
poured from alginate impressions, cast in gypsum and
conventionally trimmed, were collected as well. They
reproduced the full arches with no surface damage. The           Figure 1. Dental crown distances chosen for the study in the right side
casts were imaged by a laser scan (iSeries, Dental Wings,      mandibular arch. The corresponding distances were selected also in the
Montreal, Canada), and their 3D digital models obtained [1].   left side maxillary arch: a) Mesiodistal distance of tooth 41; b) Mesiodistal
The work described was carried out in accordance with          distance of tooth 43; c) Mesiodistal distance of tooth 44; d) Mesiodistal dis-
The Code of Ethics of the World Medical Association            tance of tooth 46; e) Distance from vestibular to lingual cusp of tooth 44; f)
                                                               Distance from mesial-vestibular to mesial-lingual cusp of tooth 46.
(Declaration of Helsinki). Informed consent was
obtained from all patients, and their privacy rights
observed. Considering the retrospective nature of the
study, no ethical approval was required. No clinical
information was retrieved from the database.
Twelve dental distances (Fig. 1) were measured on dental
plaster casts using a digital calliper; on digital 3D CBCT
images using inVivoDental software (Anatomage, San
Jose, CA); and on laser scanned surfaces using Mirror®
Vectra Software (Canfield Scientific, Fairfield, NJ).
Two different operators performed all measurements
twice. A previous calibration session was performed:
each operator made the whole set of measurements on
a dental plaster cast and on its digital reproduction, as
well as on the CBCT images of a patient not included in          Figure 2. Mean differences between measurement methods. MD: Me-
the study. The results were discussed until a consensus        siodistal distance; VL or VP: vestibulolingual or vestibulopalatal distance. *:
                                                               P = 0.002, Kruskal-Wallis test.
about landmark location was obtained.
Intra- and inter-operator reliability was assessed by          the best for plaster casts (all larger than 93%). The intra-
Bland-Altman analysis, and for each comparison both            and inter-operator reliabilities were comparable.
the reproducibility coefficient and the bias (difference       The three different techniques gave very similar
between measurements divided by the mean value)                measurements, with biases smaller than ±0.1
were calculated [7, 18].                                       mm, except the calliper-CBCT comparisons of the
The mean values were computed separately for tooth             mesiodistal diameters of teeth 41 and 24 (Table 2).
and measurement (mesiodistal and vestibulopalatal or           Reproducibility ranged between 90 and 100%; the
vestibulolingual crown diameters). The three different         comparisons between plaster and digital casts had the
techniques were compared by Bland-Altman analysis              best reproducibility coefficients (all larger than 97%).
and Kruskal-Wallis test, with the Wilcoxon test for post-      The mean differences (± 1 SD) for calliper-digital,
hoc comparisons.                                               digital-CBCT and calliper-CBCT measurements were
For all tests, the statistical significance level was set to   respectively 0.09±0.14, 0±0.3, 0.09±0.37 mm (Fig. 2).
p < 0.01, with the Bonferroni correction for post-hoc          Only three differences were larger than 0.5 mm, which
comparisons.                                                   represents the threshold for clinical acceptability [7,
                                                               18]: calliper-CBCT for teeth 41 and 24, and digital-CBCT
                                                               for tooth 24 (all mesiodistal crown diameter). Calliper
3. Results                                                     measurements slightly overestimated digital cast
The intra- and inter-operator biases ranged between 0          values, while the other differences were more scattered.
and 0.34 mm, and only 3/72 biases were equal to larger         Only the mesiodistal distance of tooth 24 (Kruskal-
than |0.3| mm (Table 1). These biases were observed for        Wallis test, p = 0.002) was significantly different among
the vestibulopalatal diameters of teeth 24 and 26 (intra-      techniques (Table 3).
operator analysis), and the vestibulopalatal diameter of
tooth 26 (inter-operator analysis). Reproducibility ranged
between 72 and 99%, the worst coefficients were found          4. Discussion
for CBCT measurements (18/24 were lower than 90%),             In the present investigation, we compared dental



Stomatology Edu Journal                                                                                                                             39
                   ARE DENTAL MEASUREMENTS TAKEN ON PLASTER CASTS COMPARABLE TO THOSE
                   TAKEN FROM CBCT IMAGES AND LASER SCANNED SURFACES?

Original Article    Table 1. Intra- and inter-operator repeatability (Bland-Altman analysis).
                                                                             Intraoperator                                                    Interoperators
                                                     Central               First First    First First                     Central                First First    First First
                                                                Canine                                                              Canine
                                                     incisor           premolar molar premolar molar                      incisor            premolar molar premolar molar

                                                                                                      Vestibulopalatal/                                           Vestibulopalatal/
                    Hemiarch                                       Mesiodistal                                                       Mesiodistal
                                                                                                      Vestibulolingual                                            Vestibulolingual

                               Left maxillary
                    Calliper           Bias            0.07      0.02         0.04       0.01           0.01       0.07     0.03     0.02      0.03        0.03     0.04       0.03

                                Reproducibility        96         95           95         99             95        97       98       99         97         99        98           95

                    Digital            Bias            0.03      0.13         0.14       0.05           0.00       0.23     0.04     0.06      0.20        0.16     0.16       0.21

                                Reproducibility        96         95           95         93             94        95       98       94         95         98        94           97

                     CBCT              Bias            0.06      0.22         0.21       0.16           0.30      0.30      0.05     0.12      0.19        0.12     0.03       0.34

                                Reproducibility        91         87           83         87             78        78       91       90         94         80        75           72

                         Right mandibular

                    Calliper           Bias            0.02      0.00         0.04       0.06           0.03       0.04     0.05     0.03      0.06        0.05     0.04       0.07

                                Reproducibility        96         97           98         96             93        95       96       98         97         98        97           94

                    Digital            Bias            0.08      0.28         0.06       0.14           0.02      0.13      0.00     0.26      0.28        0.08     0.25       0.01

                                Reproducibility        98         88           93         96             90        81       97       94         89         94        94           89

                     CBCT              Bias            0.10      0.06         0.04       0.20           0.04      0.21     0.10      0.25      0.24        0.04     0.09       0.10

                                Reproducibility        87         93           86         89             87        75       72       94         90         94        82           82

                   Bias values (absolute values) are in mm, reproducibility coefficients are in %


                    Table 2. Bland-Altman analysis for the three measurement methods.
                                                                           Central                               First     First
                                                                                           Canine                                            First premolar         First molar
                                                                           incisor                             premolar    molar

                                          Hemiarch                                                  Mesiodistal                                Vestibulopalatal/ Vestibulolingual
                        Left maxillary

                     Calliper - Digital         Bias                         0.00              0.02              -0.02      0.00                   0.05                0.04

                                                Reproducibility              100               100                99         100                     99                   99

                     Digital – CBCT             Bias                         0.05              0.00              -0.08      -0.02                  0.02                -0.01

                                                Reproducibility               99                99                99         99                      98                   95

                     Calliper - CBCT            Bias                         0.06              0.02              -0.10      -0.02                  0.07                 0.03

                                                Reproducibility               99                99                99         99                      98                   95

                      Right mandibular

                     Calliper - Digital         Bias                         0.02            -0.01                0.03      -0.01                  0.01                 0.04

                                                Reproducibility               99                99                99         100                     98                   98

                     Digital – CBCT             Bias                         0.08              0.05              -0.03      -0.03                  -0.02                0.02

                                                Reproducibility               97                98                98         99                      91                   97

                     Calliper - CBCT            Bias                         0.10              0.04               0.00      -0.04                  -0.01                0.06

                                                Reproducibility               97               98                 98         99                      90                   96
                   Bias values (absolute values) are in mm, reproducibility coefficients are in %

                   linear distances (crown dimensions) taken with three                                        intra- and inter-operator variabilities. Indeed, the
                   different techniques. Overall, differences among the                                        quantification of inter-operator reliability is necessary
                   measurements were limited, and their reproducibility                                        whenever multiple operators contribute to the analysis
                   very high, ranging between 90 and 100%. Together                                            of the same dental reproductions. The good agreement
                   with the comparison among methods, we investigated                                          between our two operators may be an effect of their
                   the variability inherent to each measurement protocol,                                      prior calibration, which should be included in all
                   namely the effect of repeated measurements made                                             measurement protocols [12].
                   by the same and different operators. We found limited                                       Apparently, this is the first study that reported inter-



   40                                                                                   Stoma Edu J. 2018;5(1): 38-42                        http://www.stomaeduj.com
                                   ARE DENTAL MEASUREMENTS TAKEN ON PLASTER CASTS COMPARABLE TO THOSE
                                                   TAKEN FROM CBCT IMAGES AND LASER SCANNED SURFACES?


operator differences: for instance, both White et al. [19]        Table 3. P values from Kruskal-Wallis test.




                                                                                                                                                      Original Article
and El-Zanaty et al. [20] assessed only intra-examiner                            Central          First  First   First  First
                                                                                          Canine
bias. Indeed, two or three different operators were                               incisor        premolar molar premolar molar
involved in other studies, but only intra-operator                 Hemiarch                     Mesiodistal                     Vestibulopalatal
variability was reported [6]. Similarly, Wiranto et al. [8]       Left
                                                                                    0.09       0.93       0.002*       0.93        0.18       0.47
assessed the variability from three different operators,          maxillary
but did not report the actual inter-operator data,                Right
                                                                                    0.05       0.55        0.86        0.36        0.93       0.44
quoting a previous investigation.                                 mandibular
The excellent reproducibility of the three different             *Significant difference p < 0.01. For significant values, post hoc Wilcoxon tests:
measurement techniques is in line with the current               Calliper – CBCT: p = 0.002; Digital - CBCT: p = 0.03.
literature reports. For instance, De Luca Canto et al.           were acceptable, while more care may be needed for
[2] made an extensive review to study the validity of            CBCT measurements, as also underlined by previous
measurements obtained from digital dental models                 studies [3, 4].
produced from laser scanning against those directly              The results are promising, nevertheless further
made on the original physical dental models. The                 evaluations on a larger sample are advised.
authors concluded that the current scientific evidence
supports the validity of digital measurements.
White et al. [19] tested the accuracy of the digital             Author Contributions
reproductions of dental models made by using CBCT                LP: design of the study, data collection and
scans, and found satisfactory values for intra-arch              interpretation, drafting the MS, final approval of the
measurements but inaccurate inter-arch relationships.            MS; MC: design of the study, data elaboration, drafting
El-Zanaty et al. [20] compared linear distances obtained         the MS, final approval of the MS; SG: data collection,
on plaster casts and from CT head scans; the two                 critical review of the MS, final approval of the MS; FMER:
techniques had excellent agreement. More recent                  data collection and elaboration, critical review of the
studies reported that both intraoral scanning and                MS, final approval of the MS; GMT: design of the study,
CBCT scanning of alginate impressions of the dental              data elaboration and interpretation, critical review of
arches gave valid, reliable, and reproducible dental             the MS, final approval of the MS; VP: design of the study,
measurements for diagnostic purposes.                            data collection, drafting the MS, final approval of the
Wiranto et al. [8] compared traditional plaster scans,           MS; CS: design of the study, data interpretation, critical
scans obtained from intraoral scans, and CBCT scans              review of the MS, final approval of the MS.
of alginate impressions, and found that the digital
reproduction of dental arches can be usefully employed
for diagnostic purposes.                                         Acknowledgments
In the current study, the worst coefficients of                  Not applicable. The study was self-funded. There are
reproducibility were found for CBCT measurements, while          no conflicts of interest and no financial interests to be
the best were those obtained for plaster casts. For CBCT,        disclosed.
similar data were reported by Kim et al. [4, 5]. Literature
is not in agreement about the technique with the best
reproducibility: both digital models [4, 5, 7], and plaster      References
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                                                                                                                          Luca PISONI
                                                                                                                   DDS, PhD
                                                      LAFAS, Laboratory of Functional Anatomy of the Stomatognathic System
                                                            Department of Biomedical Sciences for Health, University of Milan
                                                                                                                Milano, Italy

                   CV
                   Luca Pisoni, DDS, PhD, is currently a member of the research staff in the Laboratory of Functional Anatomy of the Stomatognathic
                   System - LAFAS, Department of Biomedical Sciences for Health at the University of Milan, Milan, Italy. His fields of research are
                   the morphological and metrical assessment of anatomical characteristics of craniofacial structures, dental arches, and teeth,
                   including their modifications with age, sex and pathology. He authored/co-authored some papers published in international,
                   peer reviewed Journals. He is also in private practice in Legnano (Milan, Italy).


                   Questions
                   1. Which instruments can be used to obtain a 3D virtual model of dental arches?
                   qa.         Bite wing radiographs;
                   qb.         Ultrasounds;
                   qc.         Laser scans;
                   qd.         Conventional orthopantomographs.

                   2. Which instruments can be used to obtain a 3D virtual model of dental roots?
                   qa.         Laser scans;
                   qb.         Cone Beam Computerized Tomography (CBCT);
                   qc.         Teleradiographs;
                   qd.         Surface EMG.

                   3. In the current study we assessed
                   qa.         Three different methods to measure dental diameters;
                   qb.         The effect of operator experience in making dental measurements;
                   qc.         The use of Magnetic Resonance to measure dental diameters;
                   qd.         Dental arch diameters in fully edentulous patients.

                   4. In the current study, we found that
                   qa.         Intra-operator error was larger than 20%;
                   qb.         Measurements on the ultrasound reconstructions of the dental arches were clinically useful;
                   qc.         Measurements on the laser scanned reconstructions of the dental arches were too prone to error;
                   qd.         Measurements on the CBCT reconstructions of the dental arches were clinically reliable.



   42                                                                           Stoma Edu J. 2018;5(1): 38-42                   http://www.stomaeduj.com