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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 80-86

Differentiation of evaluation of reliability of cephalometric analysis of cephalometrically diagnosed skeletal class i malocclusion using readily available digital imaging software such as IMAGE J and ICY and traditional manual tracing

1 PG Student, Department of Orthodontics and Dentofacial Orthopedics, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India
2 Proffesor and HOD, Department of Orthodontics and Dentofacial Orthopedics, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India
3 Senior Lecturer, Department of Orthodontics and Dentofacial Orthopedics, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India
4 Consultant Orthodontist, Mumbai, Maharashtra, India

Date of Submission11-Jan-2021
Date of Acceptance20-Jan-2021
Date of Web Publication22-Mar-2021

Correspondence Address:
Firoz A Khan
Room No. 108, Gomes Town, Opp Phoenix Market City, Kamani, Kural West, Mumbai - 400 070, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_231_20

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Background: The skeletal and soft tissue analysis of the face in total is a very important parameter of diagnosis. Readily available and non expensive imaging software are available which can be used for cephalometric analysis for hard and soft tissues of the face to make an appropriate treatment plan. Aims: The purpose of this study was to compare the accuracy of linear and angular measurements between the digital software IMAGE J, ICY and manual tracing. Objective: The purpose of this study was to compare angular and linear measurements obtained through manual and digital cephalometric tracings using IMAGE J and ICY software with lateral cephalometric radiographs. Material and Methods: The sample consisted of 50 lateral cephalometric radiographs. One properly trained and calibrated examiner performed the 50 manual tracing and then the same radiograph was traced digitally on a digital software. Five angular measurements SNA (Sella, nasion, A point), SNB Sella, nasion, B point), ANB (A point, nasion, B point), W angle, ULA (Upper lip angle) and three linear measurements ULT (upper lip thickness), projection of upper lip to TVL (true vertical line) & WITS appraisal were traced the conventional lateral cephalogram of 50 participants were obtained. Manual tracing was done and hard tissue landmark including the above mentioned angular and linear variables were marked. In a similar way a soft copy of the above 50 radiograph was obtained and uploaded in the digital imaging software IMAGE J and ICY. Results: SNA, SNB, ANB, W angle, WITS appraisal, upper lip thickness (ULT) upper lip angle, (ULA), projection of labrale superioris to TVL showed statistically significant values when measured manually and by digital software methods. Values measured by software methods had less errors. Conclusion: The results show statistically significant values between manual and digital tracing. The actual variation lies in identification of landmarks and their measurements. landmarks are identified better in software methods than manual methods and also there was a difference in measurements of angular and linear values of soft and hard tissue landmarks.

Keywords: Cephalometrically diagnosed, digital imaging software, manual reliability, skeletal malocclusion

How to cite this article:
Khan FA, Joneja P, Choudhary DS, Ahmed R, Tikekar S. Differentiation of evaluation of reliability of cephalometric analysis of cephalometrically diagnosed skeletal class i malocclusion using readily available digital imaging software such as IMAGE J and ICY and traditional manual tracing. Indian J Dent Sci 2021;13:80-6

How to cite this URL:
Khan FA, Joneja P, Choudhary DS, Ahmed R, Tikekar S. Differentiation of evaluation of reliability of cephalometric analysis of cephalometrically diagnosed skeletal class i malocclusion using readily available digital imaging software such as IMAGE J and ICY and traditional manual tracing. Indian J Dent Sci [serial online] 2021 [cited 2021 Apr 20];13:80-6. Available from: http://www.ijds.in/text.asp?2021/13/2/80/311687

  Introduction Top

The crucial role of cephalometrics, introduced by Broadbent in orthodontic diagnosis and treatment planning does not need any reprise [1],[2]. Savinsu et al. in an article in 2007 stated that precision and reproducibility in data obtained from cephalometrics are important for the orthodontist. Baumrind, Frantzinin 1971 stated that cephalometric analysis could be used to predict the surgical outcome, for treating severe dentofacial deformities [3]. Hand measurements are time-consuming, and there is a chance of misreading the measuring instruments and registering data (Greelen W, 1998). If digitization is carried out, then the angles and linear measurement are automatically calculated which can eliminate the errors in drawing lines between the landmarks and in the measurements with manual geometric devices[4]. In clinical orthodontics, the efficacy of both commercially available cephalometric tracing software programs and readily available imaging software for cephalometric analysis need to be evaluated for accuracy. For a long time, the manual method is considered reliable and the only method used for implementing and obtaining cephalometric tracings, and angular/linear measurements required for the interpretation of various cephalometric analysis, treatment planning, and evaluation of dental, skeletal growth, post-treatment evaluation, and research work.[5],[6],[7],[8],[9],[10],[11] The main drawback of this method is that it is more time-consuming, particularly for orthodontists and was subjected to a high degree of operator error. Although the radiographic film is stable, its tendency is to deteriorate over time which leads to a loss in the quality of the radiographic image. After that a continuous technological advances and researches in computing combined with scientific advances in dental radiology resulted in the development of computer programs designed to perform cephalometric tracings and measurements and different types of analysis. Therefore, in 1960s and early 1970s, computers played a key role in the search for quantitative information regarding orthodontic diagnosis and events associated with craniofacial growth and development. The number of programs is available in the domestic and international market that offers a wide range of features. They are now used widely used in orthodontics and cephalometric tracings. Orthodontics has benefitted more than any other dental specialty from computerization for tracing and quantitatively measuring all the values and making a treatment plan. Since the cephalometric analysis method is frequently used by orthodontists and researchers and due to continuous advances in cephalometric software, the need was felt to assess and compare the accuracy of cephalograms by manual methods and digital measuring software using IMAGE J and ICY.[12] Here, manually identified landmarks on the screen displaced digital images are used for cephalometric analysis as a comfortable alternative.[13],[14] Therefore, the present study is carried out to find out the validity of the free of cost and readily available imaging software such as IMAGE J and ICY for the hard tissue and soft-tissue cephalometric analysis, by comparing its accuracy and adequacy with the traditional manual tracing method.

  Materials and Methods Top

Fifty pretreatment cephalometric radiographs of patients were chosen based on the following criteria:

  • Both males and females
  • All teeth present
  • Good quality radiographs with no obstruction in the identification of anatomical landmarks
  • No previous history of orthodontic treatment The cephalometric analysis was done by the following two methods:

    1. Manual
    2. Digital.

Manual method

All the lateral cephalograms were taken in the natural head position.[15] These cephalograms were traced using a sheet of acetate tracing paper. The tracings were done on a view box with the tracing paper securely positioned over the radiograph with masking tape. After the tracings were done on the lateral cephalogram, the following hard-tissue landmarks were identified. Once the landmarks were traced, the lines and planes were obtained, and measurements were recorded using five angular measurements (SNA, SNB, ANB, W ANGLE, and UPPER LIP ANGLE) and two linear measurements (WITS APPRAISAL and UPPER LIP THICKNESS)[11],[16],[17] [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Figure 1: Armamentarium used for tracing

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Figure 2: Manual tracing

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Figure 3: Schematic representation of angular measurements SNA, SNB, and ANB

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Figure 4: Schematic representation of angular measurement, W-ANGLE

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Figure 5: Schematic representation of linear measurement, WITS APPRAISAL

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Figure 6: Schematic representation of linear measurement, upper lip thickness

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Figure 7: Schematic representation of angular measurement, upper lip angle

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Figure 8: Schematic representation of linear measurement, projection of upper lip to TVL

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Digital method

The digital image of each cephalogram was obtained by transferring the selected images archives of the cephalogram folder to the IMAGE J and ICY. The cephalometric landmarks were identified on the displayed image and digitalized onscreen [Figure 9] and [Figure 10]. The fifty cephalometric radiographs were scanned into the digital format and exported to the IMAGE J and ICY imaging software. It was observed that during image scanning to determine the amount of expansion and establish a proportion for the scanned images.[18],[19] The images were converted to JPEG format and saved with the maximum quality with the Imaging program. When necessary, images were manipulated and enhanced with brightness, contrast, and magnification to identify the areas with greater accuracy [Figure 11], [Figure 12], [Figure 13], [Figure 14].
Figure 9: Digital Image on IMAGE J software

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Figure 10: Digital image on ICY software

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Figure 11: Measurement of SNA, SNB, and ANB angle through digital imaging

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Figure 12: Measurement of W angle through digital imaging

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Figure 13: Measurement of WITS APPRAISAL through digital imaging

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Figure 14: (a-c) Measurement of upper lip thickness, upper lip angle, and projection of upper lip to TVL through digital imaging

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  Results Top

All the measurements were tabulated and assessed. The paired t-test was done to compare the values between manual tracing and digital IMAGE J and ICY tracing, as shown in [Table 1] and [Table 2]. The result with paired t-test shows nonsignificant difference between all the variables. This shows that the software method is an efficient method of measuring the cephalometric parameters [Table 1]. The Pearson correlation was done between the manual tracing, and the software tracing was done. The test result shows a high degree of correlation (strong correlation) in all the variables which shows that software tracing is a highly efficient method of tracing [Table 2].
Table 1: Comparision of the parameter by clinical and software method

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Table 2: Correlation of different parameters measured by clinical and by using software

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  Discussion Top

Cephalometric radiography is one of the most essential tools for the diagnosis, treatment planning and for studying growth and development of craniofacial complex, and evaluation of pre- and posttreatment changes. IMAGE J software and ICY software have the ability to measure linear and angular measurements of soft and hard tissues. In orthodontics practice, the accuracy of measurements between computerized software tracing and commonly used manual cephalometric analyses need to be evaluated to see the efficiency that will help the clinician to select appropriate methods of analysis. [20],[21],[22],[23] Therefore, this study was conducted to assess the cephalometric measurements by manual tracings and computerized tracings using IMAGE J and ICY software.[12] The aim of this study was to compare the accuracy of cephalometric readings of manual tracing of cephalograms to digital software tracing. As the conversion of an analog image to digital format involves many steps such as the hardware, software, computer functions, and settings, the likelihood of image distortion is increased. The manual method is time-consuming along with more human errors. The reproducibility of cephalometric points in the conventional method on paper in comparison to the analysis of digital images was controversial for a long time. The complicated process to obtain a digital record of radiograph, loss of data during digitization resulting in reduced quality of the image, or complicated and not sufficiently tested software analysis disputable in the past. Nowadays, due to the technology advancement and necessity of data mobility, the manual method is becoming a handicap.[24],[25],[26],[27] Serial radiographic measurements obtained from the manual tracing and digital tracing of the values of the landmarks such as SNA angle, SNB angle, ANB angle, WITS APPRAISAL, W angle, upper lip anterior, protrusion of lip to TVL, upper lip angle determines that there is a correlation between the soft-tissue and hard-tissue measurements.[28],[29],[30],[31],[32],[33] Digital techniques of tracing require the use different methods for detail enhancement to facilitate an accurate tracing. IMAGE J software creates digital tool based upon which we can measure the angular values of SNA, SNB, and ANB required from cephalogram for the treatment planning of orthodontic treatment. Then, realizing the limitation in analyzing the remaining parameters, there was a need to use a modification of IMAGE J software known as ICY software. The ICY software does both linear and angular measurements with greater ease, and therefore, the values of soft-tissue analysis of upper lip anterior thickness, protrusion of upper lip to TVL, and upper lip angular, wits appraisal and W angle are measured using ICY software. The digital tracings of all the above-mentioned angles and linear measurements were in harmony with the manual tracings of the same. Furthermore, it was less time-consuming and provided ease of storage and retrieval. So far not much research on cephalometric analysis has been done using IMAGE J and ICY softwares and other such digital imaging software. Further researches on the use of imaging software in analyzing cephalograms may prove that they are cheap/free, readily available, user-friendly, and reliable methods of cephalometric analysis as compared to the expensive options. The differences in the values were most probably due to the difficulty in identification of landmarks in the digital version of the radiograph due to change in image quality and morphing of the radiographs as well as differences in the measurements of the values for the analysis due to inaccurate landmark identification. The ease of identification of anatomical landmarks in the analog radiographs as well as the reliability of manual recordings of the analysis values makes manual tracings a more accurate and dependable method for cephalometric analysis.

  Conclusions Top

Although small discrepancies were found between the hand-tracing and computerized measurements, the differences were minimal, clinically acceptable, and nonsignificant. The user-friendly and time-saving characteristics of computerized tracing make this method inherently preferable to hand-tracing for cephalometric analysis of radiographs used in the diagnosis, treatment planning, and the evaluation of treatment outcome. Based on this study and the results obtained by comparing dental, skeletal and soft-tissue measurements using manual and digital tracings, it is justified to conclude that the manual and digital tracings show the statistical significant difference and imaging software such as Image J, ICY can be used in orthodontic practice.

This study knocks at the further doors of research to validate this research completely.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

  [Table 1], [Table 2]


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