Digital Imaging in Orthodontics

Contents:-

 Introduction :

 Digital Photography :

 Digital Radiography :

 3 D Imaging :

 Digital Models :

 Occlusograms :

 References :

INTRODUCTION :-

An analog image, such as a radiographic film, has virtually an

infinite number of elements, with each element represented by a
continuous gray scale.

Imaging and Image acquisition:

Images

Characteristics of digital images

 A digital image is composed of picture elements (pixels) that are

arranged in a 2-dimensional rectangular grid, with each pixel having a
specific size, color, intensity value, and location within the image.

 A pixel is the smallest element of a digitized image.

 Radiographic images generally use gray color with an intensity value

between 8 bits (28 or 256 shades of gray) and 12 bits (212 or 4096
shades of gray).

 Image resolution refers to the degree of sharpness of the image.

  Resolution is determined by the number of pixels per given length of
an image (pixels/ mm), the number of gray levels per pixel (bits), and
the management of the gray levels.

 The quality of an image depends on both the number of pixels and

the number of gray levels which make up the image.

 DIGITAL PHOTOGRAPHY

 Digital photography is essentially the same as conventional

photography except that in the place of the photographic film the
camera stores all of its images onto a computer chip or a similar
storage medium in a digital format.

Advantages of Digital Photography:-

- Instant viewing of pictures

– Mistakes can be rectified immediately

- No film or processing is required

- Manipulation of data on computer

- Organization of data

- No rolls – saves money in long run

- Decreases storage needs

- Transmission of data

THREE STEPS OF DIGITAL PHOTOGRAPHY:

HOW A DIGITAL CAMERA WORKS

 The big difference between traditional film cameras and digital

cameras is how they capture the images.
 Instead of the film, digital cameras use a solid state device called an
image sensor, usually a charge couple device or complementary
metal oxide semiconductor.

 On the surface of each of these finger nail sized silicon chips is a

grid containing thousand or millions of photo sensitive diodes called
photo sites, photo elements, or pixels.

THE EXPOSURE

 When shutter release button of a digital camera is pressed a

metering cell measures the light coming through the lens and sets the
aperture and shutter speed for the correct exposure.
 When the shutter opens briefly, each pixel on the image sensor
records the brightness of the light that falls on it by accumulating an
electric charge.
 The more the light that hits a pixel, the higher the charge it records.
 Pixels capturing light from highlights in the screen will have high
charges. Those capturing from shadows will have low charges.
 DIGITAL RADIOGRAPHY:-
History:-
introduction of digital radiography:-
advantages:-
R.V.G. :-
DIGITAL CEPHALOMETRY:-
SOFTWARES FOR DIGITAL CEPHALOMETRY:-
VIDEOIMAGING:-
VIDEOCEPHALOMETRY:-

HISTORY:-

 Discovery of X-rays by Roentgen in 1895, traditional 2-D

cephalographs also known as Roentgenographic cephalometry was
introduced by Broadbent in 1931

 Digital radiography is possible since Trophy introduced the first

charge coupled device (CCD) in mid ‘80.
  Digital radiography

 Conventional X-ray source is used

 Sensor is used instead of film

 Special software reads the electrical signal and turns into a image

 Three types available:

 Direct Digital Imaging

 Indirect Digital Imaging

 Storage Phosphor Imaging

Advantages of digital radiography:

 Superior grayscale

 Reduced exposure (50 to 80%)

 Increased speed of image viewing

 Lower equipment and film cost

 Increased efficiency

 Enhancement of diagnostic image

 Effective patient education tool

Direct Digital Imaging

A number of components are required for direct digital image production.

These components include

 X-ray source,

 Electronic sensor,

 Digital interface card,

 Computer with an analog to-digital converter (ADC),

 Screen monitor,

 Software, and

 Printer.

Indirect or Scanned Digital Imaging

 Indirect digital imaging implies the image is captured in an analog or

continuous format and then converted into a digital format.

 As with any data conversion, this analog to digital conversion (ADC)

results in the loss and alteration of information.

 Storage phosphor imaging:

 It is a wireless digital radiography system.

 In this system, a reusable imaging plate coated with phosphor is used

instead of a sensor with a fiber optic cable.

 A phosphor coated plate is similar to an intensifying screen used to

expose an extraoral film in that it converts x-ray energy into light.

 Storage phosphor imaging records diagnostic data on plates following

exposure to the x-ray source and then uses a high speed scanner to
convert the information into electronic files.

 After exposure, the plate placed into an electronic processor where a

laser scans the plate and produces an image that is transferred to
computer screen.

 No chemicals are used in this processing.

CEPHALOMETRIC APPLICATIONS

 Cephalometric software is routinely used for case diagnosis and

treatment planning.
  These applications replace manual acetate tracings with computer
generated tracings derived from digitized head films.

 The datasets are also the starting point for formulation of VTO’S .

 Cephalograms are two dimensional representations of three

dimensional anatomy.

 This system first developed by Mouyen et al in 1989

 Imaging done with a CCD

 very high resolution

 optimal shape and size of the sensor

 sensor thickness 4 mm

 sensor cable diameter 3 mm

DIGITAL CEPH

 Land mark identification & computerised cephalometric analysis

have also recieved major attention.

 Human error associated with land mark location is reduced.

 It requires a scanner for image acquisition

Advantages

 It allows for multiple cephalometric analyses to be performed

simultaneously
 It also facilitate the performance of repeated digitization of
landmarks
 since it is in digital form , it can be integrated with other digital
information, such as intra oral & extra oral digital photographs &
tomographs
 Cephalometric work flow

Criteria in selecting cephalometric software

  Reliability:

 Relevance:

 Accuracy:

 On screen Measurements:

 Integration with Digital Photographs:

 Import /Export Feature:

 Windows Based Controls:

 Image Smoothing:

 Colour Coding:

 Upgradability:

 Cost:

Softwares for digital cephalometry:

videoimaging

 Videoimaging is simply the process of capturing an image and storing

it in the computers for further use.

 In live video, capture the patient is seated with the natural rest
position and a camcorder used to view the profile on the computer
moniter when the operator is satisfied that the head and lip positioned
properly.

 Frontal views of the patient are captured next.

 Intra oral views of the dentition may also be captured using a

camcorder.

Uses of Videoimaging:-
  The software superimposes the patients lateral photograph onto the
lateral cephalogram to a proportionate scale.

 When the computerized predictions are made, the patient can now
have an idea of his / her probable facial appearance after the planned
treatment.

 Videoimaging helps in diagnosis and treatment planning.

 Videoimaging helps in motivating patients and helps in patient

counselling.

Videocephalometry:

 Videocephalometry as termed by Sarver.

Uses :-

 Patient counselling.

 Relates hard and soft tissue.

 Teeth relation to face.

 Treatment planning and diagnosis.

 Communication with other professional.

3 dimensional imaging:-

 Introduction:-

 Computed tomography (C.T.) :-

 M.R.I. :-

 C.B.C.T. :-

 3D IMAGING

Selected digital imaging devices can produce digital volumes or 3D

images.
The volume element (voxel) is the smallest element of a 3-dimensional
image.

Why do we need a three dimensional record???

 In clinical orthodontics it is not enough just to accurately image the

facial shape but essential to be able to detect changes in the image.

 When evaluating the success of appliance therapy it is also important

to be able to distinguish between changes in morphology due to
treatment and changes due to other factors such as growth and
normal variation.

 In traditional cephalometry 3D craniofacial structures are projected

onto 2D radiographic film.

 This process creates cephalometric landmarks that do not exist in

patient.

 These structures are effectively optical illusions of craniofacial

anatomy. Eg: mandibular symphysis, pterygoid fossa, etc.

 Although we refer to these structures are anatomical landmarks, they

are in fact, artifacts of the cephalometric technique.

COMPUTED TOMOGRAPHY

CT was developed by Sir Godfrey Hounsfield in 1967.

Parts of the Equipment:-

1. Scanner : ( movable x ray table + gantry)

2. Computer system:

3. A display console :
  Computed tomography (CT) machines acquire image data by using
either a single narrow x-ray beam or a thin, broad, fan-shaped x-ray
beam.

 These beams rotate around the patient in a circular or spiral path as

the patient moves through the scanning machine or as the rotating
beam passes over the patient.

 CT scans avoid the superimposition of structures and are, therefore,

more desirable than conventional radiography as a morphometric
tool.

 Since its inception, computed tomography has provided quantitative

measurements for many different biological systems and has been
used in pre- and post-surgical mapping procedures, the evaluation of
developmental and regressive dental abnormalities, facial trauma,
and temporo mandibular joint disorders.

RADIATION DOSAGE FOR CT

Radiation dosage :- 1.536 rad for a single section

1.8432 rad for multiple sections

Clinical Applications:-

High radiation exposure and high cost has prevented its use in
Orthodontics.

But in certain situations like :

 In severe craniofacial deformities where 2D diagnostic records are

inadequate

 Treatment predictions with 3D computer tomographic skull models

 TMJ examination

TMJ Examination :
CT for the evaluation of the TMJ was introduced by Wegener and
colleagues for demonstrating bone abnormalities within the TMJ.

USES:-

 Useful in determining changes in bone density

 Primary imaging method when internal derangement or arthrosis is

suspected – clinical diagnosis is not always sufficient.

 Has advantages when planning treatment or operations on jaws and

TMJ diseases and deformities.

Developed by:-FELIX BLOCH in 1946

Equipment:

1. The Gantry :Patient is surrounded by magnetic coils

2. Operating console : where the operator controls the computer and

scanning procedure

3. Computer room network :

 Magnetic fields are caused by rotating electric charges.

 Essentially it is the- imaging of the water in the tissue.

 Images are generated from protons of the hydrogen nuclei of water.

 When images are displayed; intense signals show as white and weak
ones as black.

 Intermediate as shades of gray.

 Cortical bone and teeth with low presence of hydrogen are poorly
imaged and appear black.

Short coming of M.R.I :

 Inability to identify ligament tears or perforations

 Dynamics of tissue joint not possible

  Cannot be used in patients suffering from claustrophobia

Cone beam computed tomography:- (CBCT)

 CBCT was introduced in the 1990s.

 CBCT were designed to counter some of the limitations of the

conventional CT scanning devices.

 In CBCT, a single rotation of the radiation source to capture an entire

region of interest, as compared to conventional CT devices where
multiple slices are stacked to obtain a complete image.

 There are 4 main CBCT system providers in the world market:-

1) New Tom 3G (Quantitative radiology, Verona , Italy)

2) i- CAT (Imaging Sciences International, Hatfield, USA)

3) CB MercuRay (Hitachi Medical Corporation, Tokyo, Japan)

4) 3D Accuitomo (J. Morita Mfg Corp, Kyoto, Japan)

Radiation Exposure:-

In CBCT, there is less radiation (upto 4 times) as compare to

conventional CT.

Clinical application of orthodontic interest:

 Impacted teeth and oral abnormalities:-

 Airway analysis:-

 Assessment of alveolar bone heights and volume:-

 Temporomandibular joint morphology:-

Limitations:-

 Highly expensive.
  CBCT does not the ability to map out exactly the muscle structures
and their attachments.

 Long capture time for a full view of subject (scan time 30-40 sec),
during which involuntary muscle movements will lead to inaccuracies
to soft tissue capture.

 CBCT soft tissue images do not capture the true colour texture of the
skin.

 Specially trained person needed to take these images.

Basic techniques for producing digital models:

• Stereolithography:-
• Stereophotogrammetry :-
• Laser scanning :-

Stereolithography

Stereolithography is a method of organic model production based on CT

scans that enables the representation of complex 3D anatomic structures.

Stereolithography gives you a fast, easy way to turn CAD drawings into real
objects

Stereolithography also known as 3-D layering or 3-D printing, allows

you to create solid, plastic, three-dimensional (3-D) objects from CAD
drawings in a matter of hours.

Stereo lithography machine

The machine has four important parts:

 A tank filled with several gallons of liquid photopolymer. The

photopolymer is a clear, liquid plastic.

 A perforated platform immersed in the tank. The platform can move

up and down in the tank as the printing process proceeds.

 An ultraviolet laser
  A computer that drives the laser and the platform

 The photopolymer is sensitive to ultraviolet light, so when the laser

touches the photopolymer, the polymer hardens.

If you stand next to the stereolithograph apparatus (SLA), you can

actually see the laser as it builds each layer.

Shortcomings:

 Stereolithography is expensive process.

 The machines themselves usually cost in excess of $250,000.
 Need for experienced and skilled operators to obtain accurate 3D
modeling.
 No production of soft tissue in machine-readable form.

Stereo-photogrammetry

 Defined as “the science or the art of obtaining reliable

measurements by means of photographs”
 First clinical use by Thalmann-Degan in 1944
 C3D is a latest system used to produce non-contact vision based
imaging produced by Glasgow dental school and the Turing
institute
 C3D system has 2 pods with 3 cameras each
 C3D provides the clinician with a lifelike 3D model of the patient’s
head that can be rotated, enlarged, and measured in 3 dimension
as required for diagnosis, treatment planning, and surgical
outcome analysis.
 3D laser surface scan
 Straightening “crooked” teeth in the dental arch requires space,
which is commonly obtained through expansion of the arch or
extraction of teeth. The accurate assessment of the extent of
crowding in the dental arch is essential as this forms the basis for
extraction of permanent teeth in orthodontic treatment. Performing
an accurate space analysis on dental models by manually
 simulating the idealized alignment of teeth from their original
positions is a tedious laboratory process.
 The development of graphical software for 3-dimensional analysis
of crowding will help to speed up the process. It permits accurate
measurement of tooth size and dental arch length.
 Disadvantages
 Slowness of the method which takes 8 to 10 seconds to scan the
face, making distortion likely
 Need for the patient eyes to be closed during scanning or wear
protective glass which makes the identification of the image
difficult
 Inabilty to capture soft tissue texture
 Poor reproduction of the areas that lie in undercut
 Expensive

occlusograms

Micheal R. Marcotte has demonstrated the use of occlusogrms in

planning orthodontic treatment.

This procedure will permit the orthodontist to determine:-

1) The anchorage requirements :-

2) The arch length status:-

3) Final arch width :-

4) The teeth to be removed, if any :-

5) The final occlusal relationship:-

The occlusogram procedure requires accurate positive print 1:1

photographs of the occlusal aspect of oriented casts.

From these photographs tracings were made on the acetate paper of the
maxillary and mandibular teeth, showing

1. gingival tooth contour,

2.incisal edges,

3.buccal cusps ridges,

4. central grooves

5. cusp tips.

6. palatal rugae,

7. the mid palatal raphe,

 In order to orient the occlusogram tracings, the mid sagittal and

transverse registration lines are constructed.

 The maxillary mid sagittal line is constructed by connecting the mid

point of the incisive papilla, the mid palatal raphe.

 The maxillary transverse registration line is constructed distal to the

last molar in the arch perpendicular to the mid sagittal registration
line.

 The maxillary and mandibular occlusogram tracings are then

separated by cutting acetate paper mid way between both tracing.

 The occlusogram tracings are assembled using the registration dots

and the maxillary registration lines are duplicated on the mandibular
occlusogram tracing.

 Both pieces of tracing paper, when oriented can be thought of as the

maxillary and mandibular denture bases in centric relation at the
beginning of orthodontic treatment .

 For this tracing as treated earlier, the anchorage requirement,

extraction of necessary teeth, arch width determination and final
occlusal relationship could be determined at the onset of the
treatment.

Softwares for digital models

 SURE SMILE TECHNOLOGY:-

  ORTHO- CAD :-

Sure smile technology

 Sure smile technology was designed to substantially reduce errors in

treatment resulting from appliance management.

 It provides image capturing, three dimensional visualization tools for

diagnosis, monitoring, and patient communication, along with
precision appliances that can help the orthodontist deliver truly
customized care in a patient- centered practice.

Ortho - cad

 For this system 3 components are required:-

1) Computer with internet connection.

2) Hard drive for storing the incoming models.

3) Electronic browser that allows clinician to electronically retrive, view and

analyze the information.

 The program runs on MS Windows and can be viewed on computer.

 The file size of each model is about 3 MB.

 The typical cost of service is $35 per model and it is present limited to
USA and JAPAN.

FEATURES:

 3D ORTHO-CAD browser permits:-

1)5 simultaneous view of the models in the same window.

2)The antero-posterior limits of the models can be adjusted between C.R.

and C.O. and the software remembers this new relationships.

3) An occlusograms of the contacts can be generated.

4)The model can be electronically sectioned, sagitally and transversely.

5) Tooth material analysis can be calculated rapidly.

Advantages:-

 They can be sent anywhere around the world as an e-mail

attachment.

 It is valuable tool in tele conferencing with virtual display

 They can be recalled at the touch of a button at each patient visit and
displayed on a chair side moniter.

Limitations:-

 Inability to articulate the models in terminal hinge position.

 Manipulation of the model onscreen takes a small learning curve .

 They are yet to be approved for American Board Certification.

CONCLUSION

 Cranniofacial imaging is now into the "digital era" in which new digital
imaging technologies are being used to resolve previous limitations of
the patient record.

 This technology offers three-dimensional capabilities that allow vastly

improved insight and understanding of patients.

 The ultimate dream of 3D imaging and modeling is to achieve the

‘virtual orthodontic patient’, where we can see the bone, flesh and
teeth in three dimensions.

 If this can be achieved in an accurate way, it will allow considerable

data to be collected and a variety of soft and hard tissue analyses to
be performed.

REFERENCES:-
 T. M. GRABER :- Orthodontics current principles and
techniques.

 PROFITT W.R. :- Contemporary Orthodontics

 ROHIT SACHDEVA :- Sure Smile Technology in a patient-

Centered Orthodontic Practice

 (JCO-2001)

 REDMOND W.R. et al:- Clinical Implication of Digital

Orthodontics (AJODO 2000

 SARVER D. M. :- Video Imaging: The Pros & Cons

 WENZEL & GOT FRDSON:- Digital Radiography for the

orthodontist. (AJODO-2002)

 KAU & RICHMOND S. :- 3 Dimensional CBCT in Orthodontics

(JO-2005)

 W. RONALD REDMOND:- Digital Models: A New Diagnostic

Tool (JCO-2001)

 RICHARD D. FABER :- Occlusogram in Orthodontic Treatment

Planning ( JCO- 1992)