Imaging in Orthodontics

Nipul K. Tanna, DMD, MSa,*,

Anwar A.A.Y. AlMuzaini, DDS, MS, BDM, MSOBb, Mel Mupparapu, DMD, MDS, DABOMR
c

KEYWORDS

Intraoral scans
Orthodontic imaging
2D and 3D cephalometric analysis

Skeletal maturation
TMJ evaluation
Airway analysis
Obstructive sleep apnea

KEY POINTS

Historically, 2D imaging first provided a method for evaluating the relationship between
the cranium and the dentition.

Standardized methods allowed for research in growth and development.

3D intraoral scanning and imaging techniques are a game changer and have paved the
path for:
 3D analysis, diagnosis, and virtual treatment planning.
 Determination of the biologic boundaries of orthodontic treatment.
 3D evaluation of the TMJ.
 Airway analysis methodology.

INTRODUCTION

According to the current practice guidelines published by the American Association of

Orthodontists1 the following diagnostic imaging in orthodontics are considered as part
of the diagnostic records:
1. Intraoral and/or panoramic radiographs to assess the condition and developmental
status of the teeth and hard tissue supporting structures, and to identify any dental
anomalies or pathology.
2. Radiographic imaging to permit relative evaluation of the size, shape, and positions
of the relevant hard and soft tissue craniofacial structures including the dentition,
and to aid in the identification of skeletal anomalies and/or pathology.
3. Posterior-anterior (PA) cephalometric and lateral cephalometric radiographs may
be considered as part of the diagnostic imaging. Three-dimensional (3D) cone-
beam computed tomography (CBCT) may be used as an imaging source to obtain
this information.

a
Postdoctoral Periodontics/Orthodontics Program, University of Pennsylvania School of Dental
Medicine, 240 South 40th Street, Philadelphia, PA 19104, USA; b Ministry of Health, Govern-
ment Office, Jasim Boodai Street, Kuwait City, Kuwait; c University of Pennsylvania School of
Dental Medicine, 240 South 40th Street, Suite 214, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: nipul77@upenn.edu

Dent Clin N Am 65 (2021) 623–641

https://doi.org/10.1016/j.cden.2021.02.008 dental.theclinics.com
0011-8532/21/ª 2021 Elsevier Inc. All rights reserved.
624 Tanna et al

Additionally, for patients still in the growth and development stage, a hand-wrist film
for evaluating the level of skeletal maturation can also be considered.
In the age of the digital workflow era, intraoral scanners have permitted clinicians to
replace impressions and plaster casts with accurate virtual casts (e-models) that
become part of the diagnostic record. These can also be used to print 3D models
for appliance fabrication and so forth. 3D radiographic imaging merged with intraoral
scanned stereolithography files have become a powerful technological tool for 3D vir-
tual planning of orthodontic and orthognathic surgery cases.
In recent years, the introduction of CBCT imaging has provided clinicians with the op-
tion to extract two-dimensional (2D) images from a full-volume CBCT. Although 3D anal-
ysis is gaining popularity, it does have a learning curve in that accurate positioning and
proper landmark identification is challenging. With further studies, standardized method-
ology with new norms may be required. With the introduction of more sophisticated soft-
ware, the incorporation of artificial inteligence methods, and the value-added information
gained from 3D analysis, using this powerful tool for 3D diagnosis will continue to gain
acceptance as a routine part of orthodontic diagnosis and treatment planning.
As Ricketts2 stated in 1960, you cannot know how to treat a case until you know
what you are treating. The purpose of a through clinical examination combined with
appropriate diagnostic records is to provide the clinician with enough information to
“know what you are treating.”

DIGITAL INTRAORAL SCANS

As part of the diagnostic record, intraoral scans are replacing impressions and plaster
models with “digital impressions,” “e-models,” and 3D printed casts. There are many
advantages to this diagnostic record modality. Scans are electronically stored with pa-
tient records, thus eliminating model storage and allowing authorized users to view
patient records when not physically present in the office. Files are sent electronically
to authorized dental laboratories, eliminating concerns of proper disinfection and
saving delivery time. Virtual diagnostic setups can be digitally completed, and treat-
ment plans are viewed by multiple clinicians simultaneously without being physically
present when treatment planning multidisciplinary cases. In the current age of COVID,
this provides the additional advantage of minimizing in person contact (Figs. 1–3).

Fig. 1. Images captured from an intraoral scanner. (A) Maxilla. (B) Mandible. (C) Frontal view
of occlusion. (D) Right lateral view of occlusion. (E) Left lateral view of occlusion. (Courtesy
of Dr. Justin Orr, DDS, University of Pennsylvania School of Dental Medicine.)
 Imaging in Orthodontics 625

Fig. 2. Virtual casts/e-models of (A) maxillary arch, (B) mandibular arch, (C) frontal view of
occlusion both arches, (D) right lateral occlusion, and (E) left lateral occlusion. (Courtesy of
Dr. Justin Orr, DDS, University of Pennsylvania School of Dental Medicine.)

PANORAMIC RADIOGRAPH

Although magnification and distortion factors must be taken into consideration, a prop-
erly exposed panoramic radiograph provides the clinician with valuable 2D information
to view normal structures and to identify the presence of any abnormalities or patho-
logic conditions. It provides an overview of the cervical vertebrae and areas adjacent
to the hyoid bone, areas of calcifications may be visible, condylar shape, ramus heights,
the inferior alveolar canal and mental foramen, the maxillary sinuses, the nasal cavity
and septum, the orbit, dental development, pattern of eruption, the dentition and a
broad overview of the supporting structures associated with it. Asymmetrical growth
may also be detected first on a panoramic radiograph when there are large differences
in ramus heights between the right and left sides. Any area that does not appear normal
or there is suspicion of an underlying pathologic condition requires further investigation.
Fig. 4 shows the panoramic image of a 13-year-old patient in the permanent dentition
stage with condylar resorption and asymmetric ramus heights. Roots of the premolars
are shorter and the developing third molars will require further evaluation later. Rotation

Fig. 3. 3D orthodontic planning based on intraoral scans merged with CBCT images. This vir-
tual diagnostic setup allows clinicians to determine if the orthodontic movement is even
biologically possible. (Courtesy of Dr. Eric Howard, DMD, Private Practice, Levittown,
Pennsylvania.)
626 Tanna et al

Fig. 4. Panoramic radiograph of a 13-year-old patient in the permanent dentition stage

with condylar resorption and asymmetric ramus heights.

of the mandibular canines, lower incisor crowding, prominent marginal ridges, and
prominent cingulum of the maxillary incisors is also observed.

SKELETAL MATURATION INDICATORS

Hand-Wrist Radiograph
It has been recognized and well established that chronologic and skeletal maturation
ages do not necessarily correlate. As Fishman3 noted in 1979, all too often, the timing
of orthodontic treatment was determined by chronologic age and the stage of dental
development, neither of which are reliable to establish a child’s skeletal age.
In 1959, Pyle and coworkers4 established a radiographic atlas of skeletal develop-
ment using hand-wrist films. Practitioners have used this as a reference to estimate
the age of their patients. Bjork and Helm5 reported a close association between the
age at maximal growth and the age when ossification of the ulnar metacarpophalan-
geal sesamoid of the thumb occurred. In 1981 Fishman established a clinically ori-
ented method based on hand-wrist films to determine skeletal maturation.
Fishman’s SMI method uses four stages of bone maturation using six anatomic sites
on the thumb, third finger, fifth finger, and the radius. From these anatomic sites, 11
discrete stages of skeletal maturation (SMI 1–11) have been established. The 11
stages of skeletal maturation are described in Box 1. This method continues to be

Box 1
Fishman’s 11 stages of skeletal maturation

Width of epiphysis as wide as the diaphysis:

SMI 1: Third finger-proximal phalanx
SMI 2: Third finger-middle phalanx
SMI 3: Fifth finger-middle phalanx
Ossification:
SMI 4: Adductor sesamoid of thumb
Capping of epiphysis:
SMI 5: Third finger-distal phalanx
SMI 6: Third finger-middle phalanx
SMI 7: Fifth finger-middle phalanx
Fusion of epiphysis and diaphysis:
SMI 8: Third finger-distal phalanx
SMI 9: Third finger-proximal phalanx
SMI 10: Third finger-middle phalanx
SMI 11: Radius
 Imaging in Orthodontics 627

used by many clinicians today and the reader is referred to Steven Wang and Brian
Ford’ article, “Imaging in Oral and Maxillofacial Surgery,” in this issue. Fishman’s6
work for a more detailed understanding of this methodology.
The hand-wrist radiograph in Fig. 5 is that of an adolescent patient. When this radio-
graph is obtained, it is preferable to have a clear image of the hand-wrist complex,
including the radius and the ulna. In the image for this patient, the capping stage on
the middle phalanx of the fifth digit is not as clearly visible, most probably caused
by the fifth finger positioning during the exposure. The abductor sesamoid is visible,
capping is seen on the middle phalanx of the third finger, and there is no fusion on
the distal phalanx of the third finger. Most probably, this patient would be categorized
as an SMI 7 based on Fishman’s work.
Other methods for determining the level of skeletal maturity have been reported.
McNamara and Franchi7 reported using the cervical vertebral maturation method as
a guide to determine the skeletal maturation stage. With this method, data from the
second, third, and fourth cervical vertebrae are used based on the morphology. In
summary, the vertebral bodies generally have a flat inferior border in the prepubertal
stage and transform to a more concave inferior border with C3 and C4 remaining verti-
cally shorter in the circumpubertal stage and elongation of C3 and C4 is evident in the
postpubertal stage. The reader is referred to the work of McNamara and Franchi7 for a
more detailed understanding of this methodology.

Fig. 5. Hand-wrist radiograph. In the image, the capping stage on the middle phalanx of the
fifth digit is not as clearly visible, most probably caused by the fifth finger positioning dur-
ing the exposure. The abductor sesamoid is visible, capping is seen on the middle phalanx of
the third finger, and there is no fusion on the distal phalanx of the third finger. Most prob-
ably, this patient would be categorized as an SMI 7 based on Fishman’s work.
628 Tanna et al

Two-Dimensional Lateral Cephalometric Analysis

The application of anthropometric measurements was introduced to orthodontic clini-
cians in the early part of the twentieth century. Most orthodontists at the time were
evaluating dental discrepancies primarily by the interrelation of the teeth within the
jaws. In 1931, the advent of the cephalostat by Broadbent8 enabled clinicians to accu-
rately use established craniometric landmarks to evaluate skeletal and dental relation-
ships and also introduce soft tissue findings as it relates to the position of the jaws and
the dentition.
The Miriam-Webster dictionary defines cephalometric as the science of measuring
the head in living individuals. This definition is further elaborated as the measurement
and study of craniofacial proportions, the dentition, and the soft tissues as they relate
to one another. In the skeletally immature patient, this also includes growth and devel-
opment. The concept of using angles and linear measurements for evaluating facial
proportions dates back to the fifteenth century when Leonardo da Vinci used it to
study facial form. The first truly scientific attempt of a cranial measurement was re-
ported by Spigel in the sixteenth century and was coined the term “lineae cephalome-
tricae.” The measurement consisted of four lines: (1) facial, (2) occipital, (3) frontal, and
(4) the sincipital. In a well-proportioned skull, it was believed that these lines should be
equal to one another.9
From the sixteenth to the twentieth century, numerous craniologists developed
various types of analysis (eg, Camper, DeSchamps, Daubeuton, Broca, Bell, Gibson,
Soemmerring, Blumenbach, Retzius, Barclay, Huxley, and Topinard). At the meeting
of the thirteenth general congress of the German Anthropological Society, contribu-
tions were made that led to the development of what is referred to today as the Frank-
fort horizontal plane.
Roentgen’s development of X-rays in 1895 paved the path for development of the
cephalostat by Hofrath in Dusseldorf and Broadbent in Cleveland. This development
was a significant breakthrough because most orthodontists at the time were evalu-
ating dental discrepancies primarily by the interrelation of the teeth using plaster
models. Dental casts have limitations in that the articulation of casts may provide
a reasonably good evaluation of how the teeth interrelate with each other but do
not provide an accurate assessment of their relationship with the cranium. Addition-
ally, this can provide a misrepresentation of the dental position relative to the jaw po-
sition. It is possible for teeth to be projected differently depending on how the
dentition is oriented on a plaster model. Another limitation is that the growth and
development cannot be assessed by dental casts. A standardized method using a
cephalostat provided a great opportunity for researchers to study growth and devel-
opment. Therefore, the advent of the cephalostat allowed clinicians to use radio-
graphs for the purpose of evaluating growth and for the evaluation of
interrelationships between the dentition, the jaws, the cranium, and the face and
thus provide a method for determining skeletal diagnosis, treatment planning, moni-
toring of treatment, evaluation of the post-treatment outcome, and the detection of
asymmetric growth patterns.
The dynamic pattern of growth and development also has a differential component.
Based on the postnatal growth and development reported by Scammon10,11 the brain
case follows the neural growth curve gradient, whereas the face and the dentition
more closely follow the general growth pattern. With this information it is possible to
identify which landmarks may remain stable and can be used for comparison pur-
poses to study growth, diagnose and treat, monitor treatment, and evaluate the
post-treatment results based on superimposition of determined stable structures.
 Imaging in Orthodontics 629

Cephalometric analysis first requires a thorough understanding of internal and

external skull anatomy and the overlying soft tissue before anatomic landmarks con-
sisting of hard and soft tissue structures are identified. The reader is referred to any
major textbook of anatomy or an anatomic atlas to review this information. Although
the introduction of numerous analyses has resulted in identifying additional land-
marks, many of the important anthropometric points still used today were defined
by the first cephalometric workshop held in 1957 at Western Reserve University.12
The purpose of the workshop was primarily to define cephalometric points and planes,
to standardize the technique, to clarify interpretation, and to evaluate clinical applica-
tions. Contributions by Krogman and Sassouni13 were also studied during this work-
shop, the proceedings of which went on to define and validate the skeletal
cephalometric landmarks (Table 1).
Supplementing the workshop-identified skeletal landmarks, currently there are
additional cephalometric landmarks that are used by clinicians as noted in Table 2.
Robert Ricketts expanded this further with the addition of skeletal landmarks, such
as the cranium center, DC point, suprapogonion, and point Xi (Table 3). Several soft
tissue landmarks are often used for cephalometric analysis as shown in Table 4.
Since the original workshop, the total number of identified landmarks has signifi-
cantly increased, and numerous analyses have been introduced. It is beyond the
scope of this article to list all landmarks and review all available analyses. The land-
marks that are commonly used along with their respective angles, planes (actually
lines in 2D), and measurements are described further and identified in Fig. 6.
For the experienced clinician, identifying all landmarks and reviewing all reported
analyses for each patient is not practical. The objectives of a lateral cephalometric
analysis are primarily to evaluate:
1. The relationship of the maxilla to the cranium
2. The relationship of the mandible to the cranium
3. The interrelationship of the maxillomandibular complex
4. The relationship of the dentition to the maxilla
5. The relationship of the dentition to the mandible
6. The relationship between the entire complex and the soft tissue that drapes it
On a calibrated cephalometric radiograph, the described points are used for
measuring lengths, defining planes (a line in 2D), and calculating the angles associated
with them to evaluate the craniofacial complex.14,15 Several of the cephalometric an-
alyses used are shown in Fig. 6A–F and the corresponding tracings in Fig. 6A1–F1.
However, most clinicians use a combination of measurements from various analyses.
In summary, the lateral cephalometric in this case would be interpreted as a retro-
gnathic maxilla and mandible with a high angle, clockwise growth pattern, deficient
posterior facial height, open bite pattern, and proclined upper incisors.

Two-Dimensional Posterior-Anterior Cephalometric Analysis

In the transverse dimension, there are limitations with 2D cephalometry. Although the
PA frontal radiograph has been used traditionally in orthodontics for capturing the
transverse measurements, these measurements do have errors created by magnifica-
tion, patient positioning, and landmarks are sometimes difficult to see because of su-
perimposition of structures of interest. When gross asymmetries are present, PA
frontal radiographs worked well for skeletal diagnosis. Most practitioners do not
routinely use PA cephalometric radiographs; however, this modality is useful for eval-
uation of transverse discrepancies and facial asymmetries. In identifying skeletal
transverse discrepancies of the jaws, width measurements are calculated between
630 Tanna et al

Table 1
Krogman and Sassouni modification to skeletal cephalometric landmarks

A point Subspinale The deepest, most posterior midline point on the

premaxilla between the anterior nasal spine
and prosthion (alveolar point) [Downs].
ANS Anterior nasal spine The tip of the anterior nasal spine seen on the
radiograph film from norma lateralis. Also
referred to as the sharp bony process of the
anterior maxilla at the lower margin of the
anterior nasal opening.
Ar Articulare The point of intersection of the dorsal contours
of process articularis mandibulae and the
occipital bone (os temporale) [Björk]. A
junction point between the posterior border
of the ramus and the inferior border of the
posterior cranial base.
B Supramentale The most posterior point in the concavity
between infradentale and pogonion [Downs].
Ba Basion The lowermost point on the anterior margin of
the foramen magnum in the midsagittal
plane.
Bo Bolton point The highest point in the upward curvature of the
retrocondylar fossa [Broadbent] located at the
intersection of the outline of the occipital
condyle and foramen magnum.
Gn Gnathion The most inferior point in the contour of the
chin usually between pogonion and menton.
Go Gonion The point that on the jaw angle is the most
inferiorly, posteriorly, and outwardly directed.
Located on the outer curvature of the angle of
the mandible. Constructed gonion is located
at the intersection formed by the lines tangent
to the posterior ramus and the inferior border
of the mandible.
Me Menton The lowermost point on the symphyseal shadow
in norma lateralis.
Na Nasion The intersection of the internasal suture with
the nasofrontal suture in the midsagittal
plane.
Or Orbitale The lowest point on the lower margin/inferior
border of the bony orbit.
PNS Posterior nasal spine The tip of the posterior spine of the palatine
bone in the hard palate.
Po Porion The midpoint on the upper edge of the porus
acusticus externus located by means of the
metal rods on the cephalometer [Björk]. It is
the most superiorly positioned point of the
external auditory meatus. This is a very
important landmark still used routinely;
however, the metal rods may not allow for
accurate location of anatomic porion and it
may be significantly further away.12,14

(continued on next page)

 Imaging in Orthodontics 631

Table 1
(continued )
Pog Pogonion Most anterior point in the contour of the chin.
Ptm Pterygomaxillary fissure The lowest point on the teardrop shape of the
projected contour of the fissure; the anterior
wall represents closely the retromolar
tuberosity of the maxilla, and the posterior
wall represents the anterior curve of the
pterygoid process of the sphenoid bone.
“R” Broadbent registration point The midpoint of the perpendicular from the
center of sella turcica to the Bolton plane.
S Sella turcica The midpoint of sella turcica, as determined by
inspection. Identified as the geometric center
of the pituitary fossa.
SO Sphenooccipital synchondrosis The upper most point of the suture.

the upper and lower jaws and maxillomandibular differences in conjunction with molar
angulation may serve as a guide to determine the amount of required orthopedic
correction. It is important, however, to note that ethnic norms in this dimension
have not been well established. PA frontal radiographs have also been used for eval-
uation of the frontal sinuses, the nasal cavity, and the orbital area. Currently, this im-
aging modality is being used less frequently. With the advent of 3D imaging, any
diagnostic information gained from a PA cephalometric image is viewed in much
greater detail on a CBCT image. Fig. 7 shows a PA cephalometric image and the
cephalometric tracing associated with it. Table 5 shows the cephalometric landmarks
associated with the PA cephalometry.

Three-Dimensional Analysis
Anthropometric measurements based on dry skulls were introduced to orthodontic cli-
nicians in the early part of the twentieth century. Broadbent’s cephalostat enabled cli-
nicians to use established craniometric landmarks that were identified on dry skulls
and transfer many of the landmarks onto a standardized radiograph. This allowed
for the evaluation of skeletal and dental relationships and also introduced soft tissue
findings as it related to the position of the jaws and the dentition. There were, however,
limitations in that some landmarks were difficult to identify on a 2D image, some land-
marks between the right and left side were superimposed, and magnification errors
were introduced and had to be accounted for.16 Nonetheless, once established, ceph-
alometric radiographs provided valuable information for many research endeavors
and perhaps the most well-known of these are the growth and development studies

Table 2
Additional cephalometric landmarks currently used by clinicians

LMT Mesial cusp of the lower first molar

UMT Mesial cusp of the upper first molar
Ag Antegonion (also referred to as the antegonial notch)
LIA Lower incisor root apex
UIA Upper incisor root apex
LIE Incisal tip of the lower incisor
UIE Incisal tip of the upper incisor
632 Tanna et al

Table 3
Robert Ricketts’s modification of skeletal landmarks

CC Cranium center: A point formed at the intersection of 2 lines, basion-nasion

and pterygoid-gnathion
DC DC point: A point identified at the center of the condylar neck along the
basion-nasion line
PM Suprapogonion: Point at which shape of symphysis changes from convex to
concave
Xi Xi constructed point located at the center of the ramus; the intersection of 2
diagonals as described next:
R1: Line drawn at the deepest point on the anterior border of the ramus and
parallel point vertical
R2: located on posterior border of the ramus parallel to R1
R3: deepest point of the coronoid notch, perpendicular to R1 and R2
R4: located opposite and parallel to R3 on the inferior border of the
mandible at the antegonial notch
In the resulting rectangle draw 2 diagonals, the intersection of which is the
constructed Xi point

at numerous well-known institutions. With time and wider acceptance, the lateral
cephalometric radiographic became a standard in orthodontic treatment.
With technological advances occurring at such a rapid pace, CBCT imaging has
allowed for more accurate extraction of cephalometric images from a full-volume
CBCT. However, there are many practices that are still in the early stages of incorpo-
rating true 3D cephalometry on a routine basis.

Table 4
Soft tissue landmarks used for cephalometric analysis

Tri Trichion Intersection of the normal hairline and the midline of

the forehead
G Glabella The anterior most prominent point on the soft tissue
forehead
N Soft tissue nasion Soft tissue profile’s most concave point between the
forehead and bridge of the nose
Bn Bridge of nose Midpoint from soft tissue nasion to tip of nose
Pn Pronasale Most prominent point on the anterior curve of the nose
Sn Subnasale Point along the midsagittal plane where the nose
connects to the center of the upper lip
A0 Soft tissue A point Most concave point between subnasale and the
anterior part of the upper lip
St Stomion Superius is the most inferior part on the curve of the
upper lip and inferius is the most superior part on the
curve of the lower lip
Ls Labrale superius or upper lip Most anterior part on the curve of the upper lip
Li Labrale inferius or lower lip Most anterior part on the curve of the lower lip
B0 Soft tissue B point Most concave point on the anterior curve of the upper
lip
Gn’ Soft tissue gnathion The midpoint between the most anterior and inferior
points of the soft tissue chin in the midsagittal plane
Me’ Soft tissue menton Most inferior point of the soft tissue chin
 Imaging in Orthodontics 633

Fig. 6. Identification of common hard and soft tissue landmarks on a cephalometric tracing.
(A–F) Several of the cephalometric analyses commonly used are shown as a composite image.
Corresponding tracings in A1–F1. Cephalometric tracings that correspond to cephalometric
analysis: 6A1, Steiner tracing; 6B1, Tweed tracing; 6C1, Ricketts tracing; 6D1, Bjork-Jarabak
tracing; 6E1, McNamara tracing; and 6F1, Downs tracing.
634 Tanna et al

Fig. 6. (continued)

Until recently, most clinicians who used CBCT technology extracted 2D images for
lateral cephalometric analysis purposes and for evaluation of transverse discrep-
ancies. Today, advanced technology with the advent of the CBCT merged with intrao-
ral scanning technology and sophisticated software have opened a whole new era in
3D cephalometric analysis, 3D diagnosis of the craniofacial structures, and 3D plan-
ning of orthodontic treatment. Virtual planning of orthognathic surgical treatment
and the subsequent 3D printed splint fabrication is becoming routine. This methodol-
ogy is covered in more detail elsewhere in this issue. 3D diagnosis and treatment

Fig. 7. PA cephalometric image and the cephalometric tracing associated with it.
 Imaging in Orthodontics 635

Table 5
Cephalometric landmarks associated with the PA cephalometry

Nc Christa galli The constricted upper part of the perpendicular

plate of the ethmoid bone
Ln Lateral nasal The lateral wall of the nasal cavity at its widest point
Lo Latero-orbitale Lateral wall of the orbit
Z Z point Frontozygomatic suture
Za Zygomatic arch The right and left zygomatic arches
J Jugal process Midpoint on the curve of the jugal process
Me Menton Point on the inferior border of the symphysis
A A point Point on the premaxilla between the anterior
nasal spine and prosthion

planning have truly been a game changer not just in orthodontics but also in all aspects
of dentistry.
Although the adaptation of 3D analysis does require a learning curve, it continues to
be accepted more and more by clinicians. Many 2D landmarks do not equate the
same when transferred to a 3D image. For example, a line on a 2D film may become
a 3D space on a 3D image. Further studies are required, which will allow for the intro-
duction of new landmarks, new measurements, and the establishment of new planes.
As more data are collected, new norms will also be established.
Fig. 8 shows a 3D cephalometric analysis constructed from a full-volume CBCT im-
age. One can appreciate the high-quality image and the clear identification of most
structures. Once appropriate landmarks have been properly identified, accurate mea-
surements without magnification are made. It is important to note that although the im-
ages in this document cannot be rotated, within the image analysis software, these
images can be rotated in all three dimensions.

ORTHODONTIC DIAGNOSIS, TREATMENT, AND THE TEMPOROMANDIBULAR JOINT

Temporomandibular joint (TMJ) morphology and symmetry plays a vital role in the
development of occlusion. Changes within the TMJ can define the orthodontic diag-
nosis and management. The positioning of the condyle within the glenoid fossa is crit-
ical in the initial orthodontic evaluation and subsequent work-up. The condyles are
generally located centrally within the glenoid fossa in healthy joints. Disk discrep-
ancies and occlusal disturbances may affect the condylar position. In growing chil-
dren, a history of trauma is elicited in many cases. If condyles are malformed or
hypoplastic because of developmental disturbances, they will affect the way occlu-
sion is presented in an orthodontic patient. When occlusion is normal initially and
the patient develops an open bite progressively, the condyles must be evaluated.
Figs. 9 and 10 show the condylar anatomy in a patient who developed anterior
open bite several years after she initially underwent orthodontic treatment.
If the condyles show evidence of hypoplasia, destruction, and/or morphologic changes
that are significant to orthodontic diagnosis, it is imperative that the practitioner takes
measures to overcome this issue without which the orthodontic treatment might fail.

AIRWAY ANALYSIS IN ORTHODONTICS

The respiratory system in humans allows for the conduction and exchange of inhaled
gases. The airway (or respiratory tract) is anatomically classified into the upper and
636 Tanna et al

Fig. 8. (A, B) A 3D cephalometric analysis constructed from a full-volume CBCT image. (Cour-
tesy of Dr. Grace Simco, DMD, MSD, Private Practice, Levittown, Pennsylvania.)

lower airway. Organs comprising the upper airway include the nose, pharynx, and lar-
ynx, whereas the lower airway includes the trachea and lungs.17 The flow of air through
the nasal cavity during sleep increases ventilation and thus stimulates breathing.18
 Imaging in Orthodontics 637

Fig. 9. CBCT in multiplanar reformatting showing the right TMJ and the condylar anatomy
in a patient who developed anterior open bite several years after the patient initially under-
went orthodontic treatment.

Fig. 10. CBCT in multiplanar reformatting showing the left TMJ and the condylar anatomy
in a patient who developed anterior open bite several years after the patient initially under-
went orthodontic treatment.
638 Tanna et al

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a sleep breathing disorder that occurs as a result of
upper airway obstruction. This obstruction can be caused by insufficient airway dilator
muscle or tongue motor tone. Because of the person’s inability to breath while
sleeping, OSA frequently results in disturbed sleep.19 This, in turn, leads to sleepiness
and fatigue during the day.20 OSA is highly prevalent among adults and has been
related to obesity and age.21
According to The International Classification of Sleep Disorders–Third edition, poly-
somnography revealing more than five events per hour of obstructive respiratory
disturbance index along with the previously mentioned symptoms, or a respiratory
disturbance index of more than 15 events per hour without symptoms, is diagnostic
of OSA.22 In addition, the most recent American Academy of Sleep Medicine guide-
lines recommend diagnosis of OSA with an adequate home sleep apnea test or poly-
somnography for adults at risk of moderate-severe OSA.20 This is important because
complications of OSA can include coronary artery disease, stroke, heart failure, and
arrythmias.23
Craniofacial structures can also be affected with resultant crossbite, mandibular ret-
rognathia, and a narrow maxillary arch reported in mouth breathers and patients with
OSA.24 A recent systematic review and meta-analysis found a strong correlation be-
tween morphologic changes of the craniofacial structures and OSA in adults.25 In at-
tempts to facilitate OSA diagnosis, CBCT has been investigated as a potential reliable
imaging modality in assessing the upper airway. A study found that the airway
morphology and anatomy is more accurately depicted on CBCT when compared
with sagittal and transverse measurements (which are typically used on lateral ceph-
alograms).26 A systematic review assessing 3D segmentation of the upper airway and
its reliability found it difficult to conclude whether a CBCT study is accurate or reliable
in modeling the airways because the evidence was lacking.24

Diagnosis of Obstructive Sleep Apnea and the Role of Orthodontists in the

Diagnosis and Management of Obstructive Sleep Apnea
The Board of Trustees of the American Association of Orthodontists tasked a panel of
medical and dental experts to create a document for guidance regarding the diagnosis
and management of OSA for practicing orthodontists. A white paper was published in
2019 that summarizes the task force’s findings and its recommendations.27
As the child grows into adolescence and adulthood, there are changes happening to
the skeletal tissues, such as growth and expansion and shrinkage of the oropharyn-
geal lymphoid tissues, contributing to the expansion of the oropharyngeal airway.
Based on current available literature, orthodontic movement of teeth does not in
any way affect the nasopharyngeal airway volume.
The gist of the recommendations is outlined here:
1. The diagnosis of OSA is performed by a physician specializing in sleep medicine by
performing an overnight sleep study (polysomnography).
2. The American Academy of Sleep Disorders developed several sets of criteria, pri-
mary and secondary to diagnose OSA.22
3. Conventional orthodontic therapy has never been proven to be an etiologic factor
for the development of OSA.
4. If nasal tissues are potentially the causative factors contributing to OSA, then nasal
surgery including correction of deviated nasal septum and turbinate reduction are
considered. This goes to prove that nasal airway plays a vital role in the overall
diagnosis and management of OSA. Because OSA analysis includes volumetric
 Imaging in Orthodontics 639

assessment of the airway to identify the changes in the airway volume, perhaps
quantifying nasal airway via segmentation might be able to give a better under-
standing of the overall volume of the nasal and nasopharyngeal airway. A recent
study by Mupparapu and colleagues28 demonstrated the quantification of nasal
airway via segmentation.

SUMMARY

The advent of the cephalostat in 1931 and the identification of anthropometric land-
marks on radiographic images initiated the process through which diagnostic
methods in orthodontics changed with inclusion of the craniofacial complex and its
relationship to the dentition. For many decades, skeletal diagnosis by means of ceph-
alometric analysis became a standard in orthodontic diagnosis. Growth and develop-
ment research in conjunction with methods of identifying skeletal maturation levels
determined the timing of treatment. In the past two decades, technological develop-
ments have propelled orthodontic imaging methods into the digital era with improved
and accurate methods of computerized 3D diagnosis while at the same time providing
the added benefit of less exposure to ionizing radiation.
3D diagnosis and virtual planning of cases with consideration given to periodontal
limitations, the TMJ, and the airway are becoming the new standard. This methodol-
ogy is truly a game changer and has added an entirely new dimension to dentistry.
Although the introduction of advanced technology and newer diagnostic capabilities
has provided a wealth of information, it does come with caveats. The information
output is only as reliable as the user input, meaning that there is a learning curve in
the process as clinicians familiarize themselves with the use of advanced diagnostic
methods. Accurate skeletal landmark identification, for example, still has concerns
and limitations. One must be cognizant that a skeletal landmark identified on a 2D im-
age may differ from that identified on a 3D image. With further research, there may be a
need to establish new norms that would be more applicable to a 3D analysis. It is also
important to mention and emphasize that with the added information comes the addi-
tional responsibility and obligation to identify abnormalities and pathologic conditions
that are within the field of view but may be outside of the practitioner’s realm and
therefore collaboration with colleagues may be advisable. With time, as this method-
ology continues to evolve, more clinicians will continue to embrace it and with
continued research, further insight will be gained to assist in accurate diagnosis to
provide guidance toward a well-designed and executed treatment plan.

CLINICS CARE POINTS

Orthodontic imaging in conjunction with the clinical evaluation allows the clinician to
diagnose skeletal, facial and dental relationships. In addition to this, it allows for monitorin of
growth and development, evaluation of the TMJ and analysis of the airway.

Digital stereolithography files generated via an intraoral scanner can be combined with
CBCT data to generate 3D images which can be used for 3D diagnosis and treatment
simulation.

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