Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e268ee276

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Journal of Cranio-Maxillo-Facial Surgery

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3D CT based rating of unilateral impacted caninesq

Sebastian Hanke a, Ursula Hirschfelder a, Thomas Keller b, Elisabeth Hofmann a, *
a b

Department of Orthodontics and Orofacial Orthopedics (Head: Prof. Dr. Hirschfelder), Universittsklinikum Erlangen, Germany ACOMED Statistik, Leipzig, Germany

a r t i c l e i n f o
Article history: Paper received 14 June 2011 Accepted 20 December 2011 Keywords: Canine Displacement Tooth axis Coordinate system MSCT

a b s t r a c t
Objective: The aim of this study was to develop a reference system for multislice computed tomography (MSCT) images to determine of the location of impacted teeth in metric terms. Study design: The CT data of 17 patients with unilateral impacted maxillary canines were selected retrospectively from existing MSCT data sets. In a reference coordinate system, dened by anterior nasal spine (ANS), posterior nasal spine (PNS), and A-point, the axis length and the inclination of the canines were determined and impacted and non-impacted canines were compared. Results: There were signicant differences between the impacted and non-impacted canines (p  0.0003) for all inclinations and the lengths in the x- and z-axes. The measurement of the inclination and sections of the impacted and non-impacted canine tooth axes showed sufcient repeatability and reproducibility. Conclusion: The coordinate system proved to be suitable for the exact metric localization of impacted teeth. 2011 European Association for Cranio-Maxillo-Facial Surgery.

1. Introduction Thilander and Jakobsson dened an impacted tooth as one whose eruption is considerably delayed and for which there is clinical or radiographic evidence that further eruption may not take place (Thilander and Jakobsson, 1968). Maxillary canines are the most frequently impacted teeth after the third molars, with a prevalence ranging from 1.80% to 3.29%, depending on the population examined (Thilander and Jakobsson, 1968; Ericson and Kurol, 1987). Hereditary and environmental factors dene the polygenetic multifactorial etiology of impacted maxillary canines (Bishara, 1998). Local factors for impaction include crowding and missing or hypoplastic lateral incisors (Stellzig et al., 1994). The orthodontic surgical treatment of the impacted canines requires a well-founded diagnosis and a precise localization of the impacted canines and the surrounding structures (Preda et al., 1997). Bishara concluded that the correct diagnosis of canine impaction is based on both clinical and radiographic examinations. Although various radiographic exposures, including occlusal lms, panoramic views, and lateral cephalograms, can help in evaluating the position of the canines, in most cases, the periapical lms are adequate for that

q This study was funded by the Staedtler foundation, Nrnberg, Germany. * Corresponding author. Department of Orthodontics and Orofacial Orthopedics, Zahnklinik 3 e Kieferorthopdie, Universittsklinikum Erlangen, Glckstrae 11, 91054 Erlangen, Germany. Tel.: 49 9131 8533643; fax: 49 9131 8532055. E-mail address: elisabeth.hofmann@uk-erlangen.de (E. Hofmann).

purpose. (Bishara, 1998). Ericson and Kurol proposed that multislice computed tomography (MSCT) image(s) is superior and provides more information than conventional radiographic methods (Ericson and Kurol, 1988). In their report, Schmuth et al. also described the extra information that can be obtained from an MSCT image in the case of an impacted canine (Schmuth et al., 1992). 3D volumetric imaging can show the inclination of the long axis of the tooth, relative buccal and palatal positions, local anatomic considerations, and the overall stage of dental development; 3D imaging has obvious advantages in the management of impacted canines (Walker et al., 2005). Owing to the anatomic structures being represented true to detail and free of overlap, MSCT scanning is perfect for determining the topography of retained and impacted teeth (Hirschfelder, 2008). Even though the 3D representation of structures has clear advantages, no 3D image-based measurements of impacted maxillary canines have been carried out in orthodontic therapy. In practice, a high level of accuracy is needed when using 3D image-based measurements, and the accuracy of 3D computed tomography (CT) has been investigated and conrmed (Lou et al., 2007; Lopes et al., 2008; de Oliveira et al., 2009). A 3D coordinate system based on an MSCT image is benecial both for the measurement of impacted maxillary canines and for the creation of orthodontic diagnoses as well as surgical treatment planning. The precise three-dimensional determination of the position of impacted canines is of outmost importance for the clinician to be able to estimate the prognosis of an impacted tooth to be aligned. Furthermore, by knowing the exact position of the displaced tooth

1010-5182/$ e see front matter 2011 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2011.12.005

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and its position to the adjacent anatomical structures, the surgeon will be able to surgically expose the displaced tooth safely and efciently. On the other hand, the orthodontist will be able to determine accurately the direction in which the traction has to be made in order to avoid contact with roots of neighboring teeth (Becker and Chaushu 2005; Becker 2010; Becker et al., 2010). Becker et al. (2010) showed in their study an unfavorable direction of traction to be the leading cause of failure in the orthodontic treatment of displaced teeth. For that reason, the detailed treatment planning on the basis of three-dimensional radiographs (MSCT, CBCT) is an essential factor for a successful outcome and will surely even gain in importance in the future because of forensic aspects. The objective of this study was to develop a reference system for the 3D processing of CT images and to precisely analyze the impaction of permanent maxillary canines in metric terms. The lengths and inclinations of the impacted and non-impacted canine axes determined in the reference system should be described and compared. 2. Material and methods 2.1. Subjects The CT data of the patients examined in this study were gathered between 1997 and 2009 at the Dental Clinic 3 e Orthodontics at the University Hospital, Erlangen. The purpose of the CT examinations was to provide precise localization and early-stage diagnosis concerning the resorption of neighboring teeth. Only patients with unilateral impacted maxillary canines were selected, whereas patients with bilateral impacted maxillary canines with cleft lips and palates, craniofacial dysmorphic syndrome, or whose contralateral canine was still erupting were excluded. The study population comprised a total of 17 patients (7 males and 10 females). The left maxillary canine (Tooth 23) was impacted in 10 patients and the right maxillary canine (Tooth 13) was impacted in 7 patients. The mean age of the patients at the time of the CT examination was 13.5 years (range: 10.6e18.1 years). For comparison e in the sense of a paired sample e the 17 contralateral, nonimpacted, fully erupted canines were also included as a control group. Because of the limited sample size, the type of impacted teeth (buccally- vs. palatinally-impacted) was not considered in the analysis. Four further sets of CT data from patients with a symmetrical facial structure (1 male and 3 females), mean age: 11.3 years (range 10.3e12.1 years) were evaluated to achieve more accurate results in the examination of the 3D reference system with regard to its accuracy, repeatability, and reproducibility. The overall number of patient data sets used in this study totaled 21. 2.2. CT data acquisition The CT examinations were carried out at the Radiological Institute of the University Hospital Erlangen and at the Siemens site in Forchheim, both Germany. Overall, a number of different MSCT scanners, such as Siemens SOMATOM Sensation 16 (n 16), Sensation 64 (n 11), Plus 4 (n 3), Volume Zoom (n 2), Emotion (n 1), and Denition (n 1), were used. The pixel size of the CT scans varied between 0.22 mm and 0.49 mm, and the number of slices was between 104 and 108 slices per scan. The image matrix was 512 512. Depending on the CT scanner, the slice thickness was between 0.4 mm and 1.0 mm (mean value of 0.61 mm). The CT examinations were carried out in the spiral CT mode under lowdose conditions and, as far as was possible, using the care dose 4D program, which allowed further optimization of patient

exposure to radiation (Hirschfelder et al., 2004). With the help of the light visor the patients skulls were positioned so that occlusal plane was parallel to the axial slice direction and perpendicular to the median-sagittal-plane of the skull. The MSCT data were imported in DICOM format in Voxim 6.1 (IVS-Solutions AG Chemnitz, Germany). In the working window, the gray value classication was optimized for each data set so that the desired skeletal and dental structures were displayed in the best possible way. These settings remained the same for all three observers so as to guarantee equal starting conditions. Based on the original axial slices, multiplanar (sagittal and coronal) as well as 3D reconstructed images were obtained. Seven reference points (Table 1), as dened by Martin (1914), were set in the axial and the correspondent multiplanar reconstructed images in Voxim 6.1. These reference points were automatically marked in the 3D reconstruction of the skull and formed the foundations for the measurement plan. After setting the reference points, the corresponding linear and angular measurements as well as the predened reference planes were determined electronically. The time interval between the repeated measurements was 4 weeks. Two measurement templates per observer were stored for each patient and were then coded with a letter/number combination so as to guarantee precise classication for data analysis at a later date.

2.3. Reference system A 3D system consisting of a sagittal plane, an axial plane and a coronal plane served as the planes of reference. All the three planes were traced from a coordinate system dened using three anatomical landmarks (ANS, PNS, and the A-point (A); Table 1, Fig. 1): - sagittal plane (sagittal, yez-direction) through the ANS, PNS, and A-point (A); - axial plane (transversal, xey-direction) through the ANS, PNS, and perpendicular to the sagittal plane; - coronal plane (frontal, xez-direction) through the ANS and perpendicular to the sagittal and axial planes. All the three planes intersected at the ANS point, which therefore represented the origin of the coordinate system. The canine axis was dened as the vector though the apex of the canine (Apex 13 (A13) or rather Apex 23 (A23)) and the tip of the canine (Tip 13 (S13) or rather Tip 23 (S23)) (Fig. 1). To describe the location of the canine more accurately, the length of this vector was projected onto three reference planes and measured in millimeters. In addition, the inclination of this vector in relation to the ANS reference point was measured in the three spatial planes of the reference system in degrees. The scan-dened data set coordinate system produced by the Voxim 6.1 software is based on the voxel matrix of the CT data set. The x- and y-axes run along the reconstructed axial cross-

Table 1 Denition of reference landmarks. Reference landmark (abbreviation) Anterior nasal spine (ANS) Posterior nasal spine (PNS) A-point (A) Denition Tip of the anterior nasal spine Tip of the posterior nasal spine The deepest point on the concave outline of the upper labial alveolar process in the median-sagittal-plane Apex of the upper right canine (tooth 13) Apex of the upper left canine (tooth 23) Tip of the upper right canine (tooth 13) Tip of the upper left canine (tooth 23)

A13 A23 S13 S23

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Fig. 1. 3D illustration of the image-based CT coordinate system in Voxim 6.1. The permanent dentition is colored blue and the impacted canine red. The illustration shows the reference landmarks (Table 1), the canine axes (A13eS13, A23eS23), and the x-, y-, and z-axes with the three different planes: sagittal (yez) plane (A), axial (xey) plane (B), and coronal (xez) plane (C).

sections, and the z-axis corresponds to the direction of the accumulation of the reconstructed slices. Hence, this data set coordinate system is dened by the scanning technology. The origin of the data set coordinate system is dened by the Voxim 6.1 program. This point is located in the upper left corner of the rst scan slice, and is therefore individually determined for each patient data set. 2.4. Database and statistical analysis The data was exported to the Microsoft Excel 2003 program (Microsoft Deutschland GmbH, Unterschleiheim, Germany). Statistical analysis was then carried out using the SAS 9.2 software package (SAS Institute Inc., Cary, NC, USA). Subsequently, within the framework of descriptive statistics for the individual parameters per spatial direction (x, y, z), mean values, medians, standard deviations (SDs), maximum values, and minimum values were calculated in terms of the respective coordinate system. To determine reliability and reproducibility, both the original measurement values (ANS, PNS, and A-point reference points in the data set coordinate system) as well as the values derived from these (lengths and inclinations in the reference coordinate system) were standardized for each patient with regard to his or her individual mean values. After correction, the variation of the measurement values was only affected by the variation of each observer (repeatability) and the variation between the observers (reproducibility). These two variances were examined in a model II variance analysis system with random effects (Bland, 2000), and were presented as intra-serial and inter-serial SD (SDintra and SDinter respectively). In addition, the total variation was indicated with the help of total standard deviation (SDtotal), which can be obtained by 2 applying the formula SDtotal (SD2 intra SDinter). Before applying

ANOVA, the programs prerequisites (deviations from normal distribution, presence of anomalies, and variance homogeneity) were checked in the following manner: As long as the skewness and kurtosis of the distribution of the measurement values remained in the range of 1 to 1, the relevant deviations from normal distribution were not taken into account. In the case of a deviation, occurrence of outliers was assumed. A value was considered as an outlier if it remained outside the range of three times the SD from the mean value. Analysis was carried out with and without outliers.

2.5. Intra- and inter-observer variation of reference points ANS, PNS and A-point The ANS, PNS, and A-point reference points (Table 1) were evaluated in relation to the data set coordinate system. All 21 patient data sets were included in this rating. Precision of the lengths and inclinations of the canines measured in the reference coordinate system was determined for 17 patients with impacted and non-impacted maxillary canines.

2.6. Comparison of impacted and non-impacted maxillary canines Within the framework of descriptive statistics,17 patient data sets involving impacted maxillary canines were evaluated with the help of the reference coordinate system (Fig. 1). The distribution parameters, as described earlier, were estimated in each group (impacted or non-impacted maxillary canines). The results were represented graphically in the form of box-whisker plots. Owing to the possible violation of the assumption of normal distribution, a Wilcoxon test

S. Hanke et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e268ee276 Table 2 Descriptive statistics of measured values used for landmark setting (mm). Landmark A-point in x-direction ANS in x-direction PNS in x-direction A-point in y-direction ANS in y-direction PNS in y-direction A-point in z-direction ANS in z-direction PNS in z-direction Na 124 124 125 125 124 124 126 125 124 Meanb 0.02 0.02 0.01 0.01 0.02 0.00 0.00 0.01 0.04 SDc 0.23 0.23 0.24 0.36 0.35 0.33 1.30 0.27 0.54 Skewd 0.13 0.07 0.09 0.25 0.11 0.30 0.01 0.08 0.50 Kurte 0.49 1.43 0.32 0.88 0.10 0.15 0.39 0.70 1.16 Median 0.02 0.03 0.00 0.00 0.05 0.01 0.08 0.03 0.07 Minf 0.63 0.77 0.62 1.07 0.87 0.92 3.08 0.87 1.72

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Maxg 0.65 0.83 0.70 1.07 0.83 0.93 3.02 0.77 1.38

Landmark, number without outliers (N), standardized mean (Mean), standard deviation (SD), Skewness (Skew), Kurtosis (Kurt), Median, minimum (Min) and maximum (Max). a Number without outliers. b Standardized mean. c Standard deviation. d Skewness. e Kurtosis. f Minimum. g Maximum. Table 3 Landmark, intra-observer (SDintra), inter-observer (SDinter) and total (SDtotal) standard deviation of reference landmarks anterior nasal spine (ANS), posterior nasal spine (PNS) and A-point in x-, y- and z-direction (mm). Landmark A-point in x-direction ANS in x-direction PNS in x-direction A-point in y-direction ANS in y-direction PNS in y-direction A-point in z-direction ANS in z-direction PNS in z-direction
a b c

SDintraa 0.22 0.22 0.24 0.34 0.32 0.28 0.97 0.27 0.54

SDinterb 0.05 0.07 0.08 0.12 0.13 0.17 0.86 0.05 0.05

SDtotalc 0.23 0.23 0.26 0.36 0.35 0.33 1.30 0.27 0.54

A-point in z-direction: 0.97 mm), whereas the inter-observer variation (reproducibility, SDinter) showed values in the range of 0.05e0.13 mm (exception: SDinter A-point in the z-direction: 0.86 mm, Table 3). The total SDtotal varied between 0.22 mm and 0.54 mm (an exception here was also the A-point in the z-direction with 1.30 mm) (Table 3). 3.2. Comparison of impacted and non-impacted maxillary canines Table 4 claries the examination results from the descriptive statistics concerning the lengths and inclinations of impacted and non-impacted maxillary canine axes in the reference coordinate system in relation to the three reference axes, or rather, planes. With all measurement values (lengths and inclinations), the SD of non-impacted canines was lower than that of the impacted canines. The values for skewness and kurtosis outside of the 1 to 1 range were found for a range of parameters, which refers to the deviations from normal distribution and is associated with the application of nonparametric tests (Wilcoxon test). There were signicant differences between the impacted and non-impacted canines for all inclinations and lengths in the x- and z-directions (signicance: p  0.0003). For the length of the canine axis in y-direction, the differences were nearly signicant with p 0.051. The results of the descriptive statistics of the lengths and inclinations of the impacted and non-impacted canines are presented in Fig. 2 (lengths) and Fig. 3 (inclinations) using box-whisker plots. 3.3. Intra- and inter-observer variation of the measured lengths and inclinations of the canine axes The precision of the measured inclinations and lengths of the impacted and non-impacted maxillary canine axes were determined using the reference data system. The descriptive statistics for measurement are presented in Table 5. The measurement results of the impacted and non-impacted canines in all the three reference planes had a SD of 1.7e2.9 for the inclinations and 0.51e0.75 mm for the lengths in the three reference directions. Only the inclination of the non-impacted canines on the axial plane had a greater SD of 5.3 . On the other hand, the skewness was either within the range of 1 to 1, or just outside (skewness of the vector of the non-impacted canine in the z-direction was 1.074), along with a whole range of leptokurtic parameters (kurtosis > 1). Following the visual assessment of the histogram, valid results were still found for the variance analysis. Furthermore, outliers could not be determined with the help of the three SD criteria.

Intra-observer standard deviation. Inter-observer standard deviation. Total standard deviation.

(Null hypothesis: difference 0, level of signicance 0.05) for paired samples was applied to compare the two groups. 2.7. Intra- and inter-observer variation of the measured lengths and inclinations of the canine axes Subsequently, the accuracy of the lengths and inclinations of the canines measured in the reference coordinate system were determined. 3. Results 3.1. Intra- and inter-observer variation of reference points ANS, PNS and A-point Examination of the intra- and inter-observer variation of the reference points, consisting of the ANS, PNS, and A-point, in the data set coordinate system mostly showed homogeneous variation in the three coordinates in the x-, y-, and z-direction. Deviation from normal distribution was indicated due to various extreme values. After identication of the outliers, 99.2% of all measurement values could be included in the data analysis of the results. The ANS, PNS, and A-point reference points showed a SD of 0.23e0.54 mm in all the three spatial directions (x, y, and z). A greater SD of 1.30 mm was only observed with the A-point in the z-direction (vertical) (Table 2). The intra-observer variation (repeatability, SDintra) of the ANS, PNS, and A-point reference points was found in the range of 0.22e0.54 mm in all the three spatial directions (exception: SDintra

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Table 4 Descriptive statistics of measured values used for canine investigation. Parameter Angle in degree Impacted canine in coronal plane Non-impacted canine in coronal plane Difference in coronal plane Impacted canine in sagittal plane Non-impacted canine in sagittal plane Difference in sagittal plane Impacted canine in axial plane Non-impacted canine in axial plane Difference in axial plane Length in mm Impacted canine in x-direction Non-impacted canine in x-direction Difference in x-direction Impacted canine in y-direction Non-impacted canine in y-direction Difference in y-direction Impacted canine in z-direction Non-impacted canine in z-direction Difference in z-direction Na 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 17 Mean 46.26 102.32 56.05 54.35 80.38 26.03 19.32 74.76 55.43 9.73 3.46 6.28 7.70 5.35 2.35 18.02 23.39 5.36 SDb 12.17 10.31 13.23 12.72 7.73 13.54 12.45 11.94 17.36 5.14 1.28 5.22 3.60 2.46 4.05 4.07 2.36 4.21 Skewc 0.68 0.79 0.09 1.50 0.06 0.91 1.41 0.46 0.55 0.36 0.01 0.09 0.74 0.27 1.33 0.04 0.07 0.20 Kurtd 0.03 0.05 0.04 4.51 0.82 1.64 4.30 0.25 0.06 1.14 0.92 1.20 0.81 1.18 2.32 0.86 0.34 0.93 Median 42.38 98.85 58.22 55.40 81.90 22.98 18.28 73.18 54.85 9.25 3.60 5.20 7.77 5.42 1.10 17.52 23.60 4.57 Mine 26.83 89.18 80.93 16.23 67.45 61.30 1.78 57.27 82.65 3.13 1.25 1.93 2.60 2.12 2.75 10.80 19.12 12.80 Maxf 70.90 125.00 31.00 74.40 94.50 6.00 56.30 101.00 17.00 18.20 5.77 14.60 16.30 9.40 13.60 24.10 28.20 0.77

Parameter (angle ( ) and length (mm)), number (N), Mean, standard deviation (SD), Skewness (Skew), Kurtosis (Kurt), Median, minimum (Min) and maximum (Max). a Number. b Standard deviation. c Skewness. d Kurtosis. e Minimum. f Maximum.

Fig. 2. Box-whisker plots for the measured lengths in mm with reference to the location of the upper canine: non-impacted (left) vs. impacted (right) in the x- (A), y- (B), and z-direction (C). The box-whisker plots describe the distribution by showing the mean (>), median (horizontal line in box), range between 25% and 75% percentiles (lower and upper side of the box, whereby the length describes the inter-quartile range, IQR). The outer horizontal limits indicate the minimum and maximum, whereby the extreme points are shown separately ( ).

The inter-observer variation (repeatability) SDintra had a variability in the range of 1.7e5.3 for the inclination of the impacted and non-impacted canine axes in the three reference planes and between 0.5 mm and 0.73 mm for the lengths of the canine axes in the three

reference directions. The inter-observer variation (reproducibility) SDinter was in the range of 0.2e0.8 for the inclination and 0.13e0.37 mm for the lengths. The SDtotal varied between 0.51 and 0.74 mm for the lengths and between 1.7 and 5.3 for the inclination (Table 6).

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Fig. 3. Box-whisker plots for the measured angles in degree with reference to the location of the upper canine: non-impacted (left) vs. impacted (right) in coronal (xez) (A), sagittal (yez) (B), and axial (xey) plane (C).

Table 5 Descriptive statistics of measured values used for precision of canine investigation. Parameter Angle in degree Impacted canine in coronal plane Impacted canine in sagittal plane Impacted canine in axial plane Non-impacted canine in coronal plane Non-impacted canine in sagittal plane Non-impacted canine in axial plane Length in mm Impacted canine in x-direction Impacted canine in y-direction Impacted canine in z-direction Non-impacted canine in x-direction Non-impacted canine in y-direction Non-impacted canine in z-direction Na 102 102 102 102 102 102 102 102 102 102 102 102 Meanb 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 SDc 1.66 2.11 2.86 2.66 2.70 5.34 0.63 0.75 0.67 0.53 0.51 0.70 Skewd 0.79 0.47 0.32 0.10 0.66 0.06 0.14 0.83 0.80 0.23 0.27 1.07 Kurte 0.60 1.15 3.15 0.42 1.24 0.36 0.69 2.12 2.66 0.05 1.36 2.40 Median 0.23 0.03 0.18 0.06 0.21 0.03 0.01 0.03 0.03 0.00 0.01 0.03 Minf 3.03 5.73 12.07 7.02 5.90 14.28 1.78 2.58 2.95 1.40 1.35 2.47 Maxg 4.67 6.67 8.83 7.38 9.08 14.20 1.72 1.60 1.47 1.20 1.77 1.58

Parameter (angle ( ) and length (mm)), number (N), standardized mean (Mean), standard deviation (SD), Skewness (Skew), Kurtosis (Kurt), Median, minimum (Min), maximum (Max). a Number (17 patient data sets 3 observers 2 measurement dates). b Standardized mean. c Standard deviation. d Skewness. e Kurtosis. f Minimum. g Maximum.

4. Discussion MSCT scans are perfect for determining the topography of the retained and impacted teeth due to the way in which they represent the anatomic structures in detail and being free of overlap (Hirschfelder, 2008). The accuracy of 3D MSCT-based images is at a good level for both linear measurements as well as for the measurement of inclinations (Cavalcanti et al., 1999, 2004;

Hofmann et al., 2011a,b). To measure the displacement of a tooth within a three-dimensional data set in a precise and objective manner, it is necessary to use an individualized coordinate system. Earlier studies have developed and used coordinate systems to examine facial asymmetries using an asymmetry index (Katsumata et al., 2005; Maeda et al., 2006). Because of the special problem and the area to be evaluated, the authors coordinate system was dened by the anatomical point of the sella, nasion and the tip of the tooth

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Table 6 Parameter, intra-observer (SDintra), inter-observer (SDinter) and total standard deviation (SDtotal) of angles ( ) and lengths (mm) of impacted and non-impacted upper canines. Parameter Angle in degree Impacted canine in coronal plane Impacted canine in sagittal plane Impacted canine in axial plane Non-impacted canine in coronal plane Non-impacted canine in sagittal plane Non-impacted canine in axial plane Length in mm Impacted canine in x-direction Impacted canine in y-direction Impacted canine in z-direction Non-impacted canine in x-direction Non-impacted canine in y-direction Non-impacted canine in z-direction
a b c

SDintraa 1.65 2.11 2.81 2.54 2.57 5.33 0.63 0.73 0.59 0.52 0.50 0.60

SDinterb 0.18 0.15 0.52 0.77 0.83 0.32 0.13 0.15 0.32 0.09 0.06 0.37

SDtotalc 1.66 2.11 2.86 2.65 2.70 5.34 0.65 0.74 0.67 0.53 0.51 0.70

Intra-observer standard deviation. Inter-observer standard deviation. Total standard deviation.

SD (SDintra 0.22e0.54, SDinter 0.05e0.13 mm, Tables 2 and 3) could be veried, which led to the conclusion that intra- and interobserver measurement accuracy was high. The SD from the A-point in the z-direction could be eliminated because the A-point is only important for the reference coordinate system in the x-direction (Fig. 1). The values found here are difcult to compare with those from the scientic literature, because in this study, the intra- and inter-rater agreement was determined by using the intra-class correlation coefcient (ICC) (Chien et al., 2009). The accuracy and reproducibility of the measurement points with the help of SD using CT 3D reconstructions of the skull were proved by former studies (Cavalcanti et al., 1999, 2004; Titiz et al., 2011). The values are to be set in relation with the pre-dened measurement inaccuracy boundaries, and the double SD should lie within these boundaries. With a pre-dened measurement inaccuracy of 1 mm and a maximal SD (SDtotal) of 0.54 mm (2 SD 1.08 mm), the double SD lies only just outside this range. In this study, sufcient accuracy, reproducibility, and repeatability were all assumed to dene a stable reference coordinate system through these factors. 4.2. Comparison of impacted and non-impacted maxillary canines When observing the descriptive statistics (Table 4), it can be noted that the SD of the inclinations and lengths of the vectors for impacted canines are, as expected, greater than those for nonimpacted canines. The reason for this is that all the impacted canines were collected into one group, regardless of the type of impaction. The study population of 17 impacted canines was too small for any division into palatal and buccal impaction. The nonimpacted canine values demonstrate normal distribution with the exception of the length in the y-direction. The greatest SD for the inclinations (SD 11.9 ) and lengths (SD 2.46 mm) reect the individual anatomy of the patients examined. When comparing the impacted and non-impacted canines with the help of the Wilcoxon test, signicant differences were detected for all inclinations, as well as for the lengths in the x- and z- direction. The differences in the length in y-direction were only found in the sense of a tendency, and this can be put down to the low number of cases (17). The inclinations of the canine axes in relation to the three reference planes are particularly suitable for comparing the canines, and in this study, highly signicant differences (signicance: p  0.0001) could be detected. 4.3. Intra- and inter-observer variation of the measured lengths and inclinations of the canine axes In this investigation, the variations of the measurement values from the corrected mean values were used to measure the accuracy and reliability of the inclination and length measurements. When observing intra- and inter-observer variation of the measurement results obtained in this study, only small SD (Tables 5 and 6), to a large extent, could be veried, which led to the conclusion that intra- and inter-observer measurement accuracy was high. Interestingly, the SD for the measurements of the inclination of non-impacted canines is greater than those for the measurements of the non-impacted canines. Impacted canines are probably easier to measure in terms of the inclination due to the signicant deviation. However, no signicant differences were found for the lengths. The values are to be assigned in relation to the pre-dened boundaries of measurement inaccuracy. The doubled SD should lie within these boundaries. With the pre-dened measurement inaccuracy for lengths of 2 mm and a maximum SD (SDtotal) of 0.74 mm (2 SD 1.5 mm), the value will be within these

axis. A relatively large eld of view is needed to map these points and, because of the position of the reference points, this must include highly radiosensitive organs, such as the lenses of the eye and the salivary glands. For this reason, we dened the reference coordinate system in this study through the anterior and posterior nasal spine and the A-point. As these reference points are in close spatial and anatomical relationship to the dentition, they permit metric evaluation of displaced canines, even with a single 3D CT image of the upper jaw. This reduces the eld of view and considerably spares the patients exposure to radiation. We also made every effort to select reference points which were readily reproducible due to their anatomical and morphological structure. The anterior nasal spine is a landmark with a very high inter-observer reproducibility (Olszewski et al., 2010) and easier to localize than, for example, landmarks positioned on large bone surfaces (Papadopoulos et al., 2005) or the most cranial limit of the dens axis, which exhibited high biological variability in our elds of view. When evaluating osseous or dental structures within a volumetric data set, it must be born in mind that the three-dimensional image depends on the proper adjustment of the segmentation. The result of this process is inuenced by the software algorithm, the spatial resolution, the contrast resolution, the thickness and degree of calcication of the bone and the experience of the operator (Periago et al., 2008). Delicate osseous structures, such as the anterior and posterior nasal spine, are particularly prone to be inadequately segmented (Papadopoulos et al., 2005). In order to exclude errors from segmentation, the anatomical reference points were specied in the axial primary sections and then automatically place in the 3D image of the skull. The next step was to dene a reference coordinate system using these points. The three reference points allowed the sagittal plane, which divides the maxilla through the middle from front to rear, to be dened, and therefore, permitted a direct comparison between the left-hand side and the right-hand side of the maxilla. 4.1. Intra- and inter-observer variation of reference points ANS, PNS and A-point The variation of the measurement values from the corrected mean values was used to measure the accuracy of the reference point assignment and reliability. When observing the intra- and inter-observer variation of these measurement results, only small

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boundaries. Similarly, the value for the inclinations with a measurement inaccuracy of 10 and a maximum SD of 5.3 (2 SD 10.7 ) only lies just outside this range. Therefore, sufcient precision, reproducibility, and repeatability could be determined for the measurement of the inclinations and lengths of canine axes. As in this study the intra- and inter-observer SD lie in the same range, the SDinter > SDintra hypothesis cannot be conrmed. This can be a result of the high level of education of the observers and the precise denition of the reference points (Table 1). The aforementioned advantages of MSCT, such as the detailed and overlap-free representation of anatomic structures, are accompanied by a relatively high level of exposure to radiation on the part of the patients (Frederiksen et al., 1995; Hirschfelder, 2008). The effective dose of radiation with MSCT Somatom 64 depends on the eld of view (FOV) and the selected investigation parameters (Ludlow and Ivanovic, 2008). In this respect, the benets of implementing MSCT examination must be weighed up against the risks on a case-by-case basis. For this reason, the low dose settings were selected for the examination protocol in this study, whereby the radiation exposure of the patient can be considerably reduced without any losses relevant to diagnosis in terms of the image information and image quality (Frederiksen et al., 1995). In addition, the dose can be reduced by a further 38% with the use of the CARE Dose4D program offered by the manufacturer (Ludlow and Ivanovic, 2008). However, CT should not be used as a general screening method, and should be restricted to cases with impaction or root resorption of permanent incisors, diagnosis of complex dentofacial deformities, or planning of combined orthodontic-oral surgery interventions (Ericson and Kurol, 1987; Ericson et al., 2002; Hirschfelder, 2008, Ueki et al., 2009). CBCT is a possible alternative to MSCT. This is mainly used in the evaluation of medium and high contrast applications (teeth/bones) (Kyriakou et al., 2011). It has been reported that the CBCT provides excellent dimensional reproduction and precision (Cavalcanti et al., 2004; Walker et al., 2005; Chien et al., 2009; de Oliveira et al., 2009, Moerenhout et al., 2009), with a marked reduction in radiation exposure (Silva et al., 2008; Loubele et al., 2009). The problem with CBCT is that the range of effective dose and the image quality between different devices is very high (Loubele et al., 2008, Loubele et al., 2009, Ludlow and Ivanovic, 2008). For that reason CBCT devices have different application ranges, based on the diagnostic image quality they provide, their collimation options and their maximum FOV (Pauwels et al., 2012). In 2011, Kyriakou et al. found that due to the exible scanning conditions and therefore the possibility of modifying radiation parameters, MSCT offers the possibility of reducing the radiation exposure in the moderate to high contrast range (teeth and bones) to the level of that of a CBCT, or even less, while maintaining good and controlled image quality (Kyriakou et al., 2011). 5. Conclusion The idea for treatment-relevant 3D-oriented cephalometric diagnosis can be conrmed with the results following the development of a reference system for the 3D processing of CT images and the comparison of impacted and non-impacted maxillary canines described in this study. This study was performed on available MSCT data sets. It is to be assumed that the accuracy of the reference points is sufcient to obtain valid results from the 3D measurement of maxillary canines. However, due to the proportionally high exposure to radiation, it must be highlighted that the justied indication for 3D volume images must be within extremely narrow parameters (Hirschfelder, 2008).

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