Videocephalometry /certified fixed orthodontic courses by Indian dental academy


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Videocephalometry /certified fixed orthodontic courses by Indian dental academy

  1. 1.
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. DEFINITION Video imaging technology is a method in which orthodontist gathers facial frontal,profile,and dental images and modify them to project potential esthetic treatment goals (David .m .Sarver)
  4. 4. INTRODUCTION The continued improvement in orthodontic and surgical techniques creates a greater demand for the orthodontist to communicate with the patient and other involved professionals about the projected treatment goals and outcome.
  5. 5. Experienced clinicians often have a good mental image of what they want to accomplish with the treatment,but the patient’s ability to visualize or interpret,and thus accept, the plan has been limited.
  6. 6. Clear communication of treatment goals and potential options of treatment are important aspects of today’s concepts of informed consent and clinical practice. Orthognathic surgeries need clear communication and attention. A Pioneer oral and maxillofacial surgeon once stated “Big Surgery, Big problems!”.
  7. 7. Computerized video imaging technology offers a mutual visual template by which dentists,orthodontists,oral and maxillofacial surgeons,and plastic surgeons can effectively communicate with patients and with each other. Co-ordination of calibrated lateral ceph with facial profile images permits precise measurement of bony and dental movements, and through the application of algorithmic prediction ratios,images are produced that express the expected surgical and/or orthodontic outcome
  8. 8. This improvement in visualization and quantification can help to remove some of the guesswork involved in surgical treatment planning.
  9. 9. This topic covers the transition from conventional treatment planning to computer assisted planning and how the merging of technology and contemporary dental and profile treatment planning has occurred.
  10. 10.  In a study by Kiyak(1982) he found that 53% of female patients and 41% of male patients listed esthetics as a major factor in their decision to proceed with orthognathic surgery.  In a study by Saver et al (1988)of patients whose surgeries were planned interactively with video imaging,90% patients reported that the final result was as good as or better than the predicted image.
  11. 11. Video imaging technology has the potential to touch almost every aspect of the orthodontic practice. Its advantages are     Diagnosis and treatment planning Communication at consultations Database management Communication with other offices
  12. 12. EVOLUTION There are 5 general methods of visualizing, planning and predicting surgical orthodontic outcomes: 1) Manual acetate tracing “cut &paste” techniques as described by Cohen, Mc neill et al and Henderson. 2) Manipulation of patient photographs . 3) Computerized diagnostic and planning software that produces a soft tissue profile “line drawing” as result of manipulation of digitized structures of lateral cephalometric radiographs.
  13. 13. 4) computerized diagnostic and planning software that integrates video images with patients lateral ceph. 5) 3-D computer technology for planning and predicting orthognathic surgery(moss et al).He expanded on the early methods of 3-D planning by including laser scanning to model the soft tissue response to hard tissue movements
  14. 14. 3-D TECHNOLOGY
  15. 15. ACETATE TRACING OVERLAY METHOD The most commonly used method in the prediction of profile outcome with orthognathic surgery is the use of acetate tracing manipulation. This was first introduced to orthodontists in 1970’s.
  16. 16. METHOD Cephalogram is obtained with patient’s soft tissue and lips at rest.The hard and soft tissue outline is traced onto a sheet of matte acetate paper with a 0.5 mm lead pencil. Tracing of incisal and cusp outlines of all teeth &occlusal plane should be clearly visible. Then simulated tracing done by simply placing the incisors in normal overbite & over jet relation &placing posterior teeth in occlusion
  17. 17. The planner retraces the profile outline,with a ruler measuring the ratio of hard tissue and soft tissue response and apply a BEST GUESS Disadvantages: Involves lot of guess work Crude & time consuming Trained and experienced orthodontists & oral surgeons can make a mental image, but the patients ability to interpret was much more limited
  18. 18. Utilizing the prediction tracing. A. Desired orthodontic change in the mandible. B. Desired orthodontic change in the maxilla. C. Desired position of the teeth prior to surgery to allow desired anteroposterior change at surgery. D. Superimposition showing desired orthodontic change following surgery.
  19. 19. PHOTOGRAPH MODIFICATION In an attempt to improve communication with patients,this was proposed,as a method of illustrating to the patient the soft-tissue results of the suggested plan
  20. 20. METHOD The photographs are physically sectioned;the cut-outs represents the parts that will be moved in the planned osteotomies and are arranged to simulate surgical movements Advantages: It gives the patient better visualization of the profile changes than a acetate tracing does.
  21. 21.
  22. 22. Disadvantages:  Does not permit change to soft tissue contours that occurs with treatment  Unavoidable gaps in photo have an unnatural appearance  An experienced clinician with artistic skill are essential with this methodology
  23. 23. COMBINING PHOTOS WITH CEPHALOGRAMS Henderson in 1974 presented the idea of combining cephalometric tracing with sectioned transparent profile photographs to assess predicted skeletal movements and soft-tissue profile changes
  24. 24. METHOD: As described by kinnebrew et al AJO1983 MATERIALS:An accurate lateral ceph taken in centric relation,with relaxed soft tissues and visual axis paralleling the horizon 35 transparent photo in slide Radiographic view box Vertical surface for projecting the slide Acetate tracing paper & suitable lead pencil
  25. 25. TECHNIQUE: The ceph is traced in the standard fashion,including the hard and soft tissue outlines The 35 mm slide of patients profile photo(transparent)projected onto view surface The ceph tracing is overlaid onto photographic image.the image is adjusted until the soft tissue outlines coincide.exact parallelism is difficult because of radiographic magnification
  26. 26. The facial features,including ears,hairline,forehead,eyes,eyelid,nose,lips,chin and neck are then traced onto a clean acetate sheath with contoured shaded. The image is then redrawn adjusting the dysmorphic parts to the unchanged part of the face to effect balance of the profile and to restore normal is a composite tracing.
  27. 27. The composite tracing can be modified to simulate dental and skeletal changes.Then, by using the appropriate soft-tissue displacement ratios,the overlying soft tissue can be artistically contoured into its predicted position. Disadvantages:  process is time consuming  Magnification factor should be taken into consideration
  29. 29. ERA OF COMPUTERS Initial uses of computers involved basic image modification of profile images obtained with either a  Video or digital camera  Conventional scanner  Scanner which can take 35 mm slides
  30. 30. Computer assisted cut & paste movements (morphing)were used to modify the image in an effort to describe the anticipated profile or facial result from dental or osseous movement Advantages  Proved to be useful in describing gross facial changes expected with orthognathic surgery.
  31. 31.
  32. 32. Disadvantages:  Incapable to visualize the underlying dental or osseous relation  This is critical because functional correction of malocclusion is our primary treatment goal  This virtually dictates our need for superimposition of the cephalometric radiograph and the face.
  33. 33. PHOTOCEPHALOMETRY It was a precursor to videocephalometrics. In 1978 Hohl et al proposed a photocephalometric technique for taking cephalometric radiographs and photo images that could be accurately superimposed.
  34. 34. TECHNIQUE Involves taking a photograph and cephalogram of the patient in the same position and from the same distance. The photograph negative could be enlarged and accurately superimposed on the ceph to allow visualization of the profile changes that would occur with craniofacial osteotomies.
  35. 35. ACCURACY: A study by Phillips et al investigated the accuracy of photocephalometry.A grid was placed at a position that corresponded to the patient’s mid sagittal plane and then a camera was mounted on a tripod that directly corresponded to the ceph radiographic source. Photograph and cephalograms of the grid were taken and evaluated.
  36. 36. Study concluded that,this technique provided images that could be superimposed to a certain degree,enlargement factors between cephalogram and photographs were of great magnitude. This reflects the need for development of algorithms to further refine the predictability.
  37. 37. Advantages: A more detailed visualization of soft tissues in the frontal and lateral views A more accurate analysis of soft to hard tissue relationships,particularly of soft tissue thickness.
  38. 38. Disadvantage: The differences in the enlargement factors between the photographic and radiographic images are of such magnitude that the super imposition of the two images is not feasible for quantitative comparison of soft and hard tissue anatomy.
  39. 39. THE EVOLUTION OF COMPUTERIZED CEPH ANALYSIS AND PROFILE PREDICTION Cephalograms are 2-dimensional representation of 3-dimensional anatomy. All over the world orthodontists take ceph in highly standardized form
  40. 40. Standard head position and orientation. Standard object-source distance Standardized radiographic enlargement Digitization: Digitization is process by which analog information is converted into digital format. Digital imaging may be done in two different ways
  41. 41. Digital image may be scanned Digitally produced 1) A digital image,either photo or ceph,may be produced from the existing radiograph or photograph by scanning it into computer or the use of a mounted digital video camera. Presently scanning is the least expensive option in terms of costs.
  42. 42. 2)digital image may also be produced through digital photographs or radiographs.The digital radiography uses a digital capture plate on which image is immediately transferred to computer storage.  No need of processing  Reduced exposure to patient  Wave of future  Highly expensive,&currently not available
  43. 43. The benefits of digitization of ceph are, The laborious measurement of angle and distances by the manual use of a protractor is eliminated. Once the ceph land marks are entered through the digitizer measurement calculations are performed virtually instantaneously by the computer.This eliminates vast amounts of time required in the measurement.. And a added bonus ,the errors are avoided
  44. 44. DIGITIZATION Currently there are 3 methods for cephalometric radiograhic analysis 1)hand tracing &direct measurement 2)direct computer digitization 3)indirect computer digitization
  45. 45. Hand tracing A piece of acetate tracing paper is affixed to the ceph and a 0.5mm lead pencil is used to trace hard &soft tissue anatomy.Measurement of desired angles and distances for analysis are then performed by hand with the use of a protractor/ruler.
  46. 46. Direct computer measurement The ceph is placed on a digitizing tablet,and the anatomy and anatomical points are entered into computer through the use of an electronic pen or instrument Digitizing tablet: is made up of a fine electronic grid that includes registration points as fine as .009mm apart
  47. 47. Electronic pen: Also called as potentiometer & is of two types.pen type and cross hair cursor Pen type:an electronic pen is activated to emit signals when the tip of the pen is depressed against the ceph.This closely resembles the mechanical motion orthodontists are accustomed to.
  48. 48. D D ii rr e e c c tt d d ii g g ii tt ii zz a a tt ii o o n n
  49. 49. Cross hair cursor: This potentiometer comprises of two wires arranged in a cross-hair pattern,which are imbedded into a glass window.The electronic signal is emitted from the junction of the wires.The points to be digitized are identified by the clinician,the crosshair directly placed on the point,and the potentiometer is then activated with a button on the instrument.An electronic signal is emitted,picked up by the grid,and registered in computer memory.
  50. 50. Advantages: Once data entry is complete,the computer can instantly reconstructs the data in the form of conventional tracing or print out. Many analysis made instantly
  51. 51. Disadvantages: Instrument tends to block the view of the rest of the film Point identification very difficult Glare from the glass
  52. 52. Indirect digitization A video camera or scanner captures an image of the ceph & stores it in computer.Once the image is captured and stored in the computer,image is then displayed on the monitor and indirectly digitized via a mouse or an on-screen electronic pen
  53. 53. Comparing hand tracing with computer digitization Richardson(1981) investigated the precision of directly digitized ceph and hand traced ceph.He concluded that there is not much of difference in both methods in terms of accuracy. In a study by houston(1982),he concluded that the errors associated between the two groups was significantly insignificant.
  54. 54. Comparing direct digitization with on screen digitization In a study by jackson et al(1985 BJO),he concluded that onscreen digitization method is as good as manual tracing.There are following factors which influence the image seen by the clinician.  Distortion by the camera lens  Software distortion  Type of monitor
  55. 55. In a study by Sarver et al in which he found that computer monitor is the most common source for distortion 16%distortion on left side 11% distortion on right side No distortion in center He advocates to use flat screen monitor to eliminate this.
  56. 56. Requirements for vcd Also radiographic source,developing euipment,lightings,plain background.
  57. 57. Video imaging technique There are two phases in video imaging 1.counseling phase 2.treatment planning phase
  58. 58. Counseling phase Involves the use of facial or dental image modification without any quantitative aspect to the process. It is simply a graphic way of communicating ,concepts that are difficult to present verbally.
  59. 59. For e.g,imaged pictures or smile banks could be used to explain to patients how their teeth will look like. Procedure Pre treatment profile modification sessions may be performed with the patient before full records are the counseling phase profile image is gathered and displayed on the computer screen, & profile changes expected with surgery are illustrated through the use of cut & paste tools
  60. 60. Which is present in most imaging software packages.Cut & paste permits image modification but does not offer quantitative feedback. The changes performed on the image are displayed on the monitor may not be duplicated in the surgical, procedure because the surgeon does not know how far facial and skeletal components were moved to obtain the projected outcome image.
  61. 61. As in all phases of profile analysis and consultation, natural head position is recommended The following figure illustrates why head positioning is important in imaging.
  62. 62. Difference in lateral rotation of head,foreshortens the nose
  63. 63. SNA-NORMAL . SNB-90
  64. 64. . 15 ROTATION OF PICTURE
  65. 65. The counseling and treatment planning phases are explained along with a patient example. A adult female patient presented with a chief complaint of her class II dental relationship secondary to mandibular deficiency.she was referred by her spouse a dentist,and was considering mandibular advancement to correct her class II relationship.
  66. 66.
  67. 67. Molar relationship
  68. 68. She had been ortho treated as a child with 4 bicuspid extn but was unable to attain class I molar relationship. she presented to orthodontists for counseling to discuss her treatment options but was unwilling to commit to surgery until she had a clear idea of what she will look like.
  69. 69. An initial profile image was captured and displayed on compu screen for graphic illustration of the facial changes that should be anticipated with orthodontic decompensation and surgical mandibular advancement. The use of cut & paste art functions in the software programme allows us to copy outlined segments of the image to RAM for short term storage and graphic movement.
  70. 70. The conseling phase is performed without videocephalometric integration,but simulation of the soft tissue reaction to the planned hardtissue movements(orthodontic and orthognathic) can be performed. It is done to communicate to the patient the facial changes that would occur with pre-surgical orthodontics and outcome of orthognathic surgery.
  71. 71. procedure First the initial image is captured and displayed on the computer screen with selected ceph analysis overlaid on the profile image. Application of the ceph analysis to the profile demonstrates the dental compensation and mandibular deficiency present in this patient.
  73. 73. Simulation of orthodontic decompensation of maxillary incisors through torque and advancement of upper incisors is then performed using the cut and paste function. Profile changes expected with maxillary advancement in preparation for surgery are illustrated by advancing the upper lip on the profile image. (Look worse before you look better)
  74. 74. This is in order to mentally prepare them for the unmasking effect of decompensation. In the computer simulation, a box is placed encompassing the upper lip and copied to RAM.The box is then moved forward by the mouse.The new position reflects soft tissue reaction to decompensation.
  75. 75. Click & drag
  76. 76.
  77. 77. The next step is to simulate mandibular advancement. A new copy box is placed on the mandible and copied to RAM. This outlined portion is then moved anteriorly to simulate mandibular advancement
  78. 78. Click& drag
  79. 79. The mandible is moved forward ,the amount estimated by the clinician to correct the class II This image simulates orthodontic decompensation and correction of mandibular deficiency & class II malocclusion
  80. 80.
  81. 81. The next logical procedure is advancement genioplasty to improve chin projection.This is simulated by outlining another template on the chin,copying the section of the chin to RAM and then moving the chin anteriorly to an esthetically desired position.
  82. 82. Click& drag Simulation of genioplasty
  83. 83. The final profile created by image modification effectively communicates the anticipated effect of orthodontic decompensation ,surgical mandibular advancement,and advancement genioplasty
  84. 84. final profile
  85. 85. Pre & post counseling photos
  86. 86. In this short preliminary visit the patient has received graphic communication regarding the potential facial changes that will occur during ortho treatment & the anticipated outcome of the proposed treatment plan. After this phase of counseling, patients may then decide whether they value the esthetic changes & are reassured enough by the image modification to pursue more comprehensive treatment planning
  87. 87. Treatment planning phase The treatment planning phase of video imaging involves the integration of the facial profile image with the ceph and calibrating it to profile video so as to relate the underlying hard-tissue to overlying soft-tissue. It allows quantification of hard & soft tissue movements and to apply algorithmic response ratios between the two to project the soft-tissue reaction to hard tissue movement.
  88. 88. Judgments can be made about the basic changes needed for occlusal correction by having the ability to see where the teeth are in relation to the face.consideration can then be given to what other procedures may be needed to attain the facial and dental aesthetic goals.
  89. 89. In the adult patient the computer projection can be quite accurate.In the adult major inaccuracy is the actual treatment itself. In the adolescent the unpredictability of the growth dynamics greatly diminishes the predictive value of video cephalometric projection.
  90. 90. procedure The same patient example will be used to explain the treatment planning phase.After the profile image is captured, calibration procedures are performed when the ceph is matched to video image. The computer can then perform algorithmic calculations so that the movements on the video screen are translated into real life terms.
  91. 91. A profile treatment planning template is created by integration of the cephalogram, calibrated to the facial profile, and displayed on the computer monitor. Profile projections(hard tissue movement with appropriate soft tissue response)are drawn from the computer data base & applied in algorithmic fashion when the dental or osseous segments are moved.
  92. 92. calibration If the coordinated videocephalometric images cannot be translated into real – life measurements,then the treatment planning process has no quantitative validity. Methods: Direct digitization,a ruler is placed on the on the digitization tablet or on head film itself.The software will ask the user to digitize 2 or more points on film or ruler,which gives the comp a referrence.
  93. 93. In programmes where tablet is not used & the head film is imaged through a video camera or a scanner ( in -direct digitization) Two methods of calibration.  Grid  two point system
  94. 94. In first method ( Grid ) A grid is placed on a light box,& a mounted video camera takes a picture.In the soft ware a preset grid is already in place to match-up with grid in the light box.By zooming the lens calibration done. Second method: (two point system) Requires identification of two points on the radiograph.The same two points are identified on the comp screen using a calibration feature in the software.
  95. 95. A profile planning template is created by integration of ceph,calibrated to the facial profile and displayed.
  96. 96. Simulation of orthodontic decompensation is created by up righting and advancing the upper incisor template. The computer not only allows overlay &visualization of the pretreatment tracing & projected dental movement but also measures these anticipated and planned movements, which are reflected in a table on the left, which is shown in the figure.
  97. 97. anticipated and planned movements, which are reflected in a table
  98. 98. Simulation of orthodontic decompensation is created by up righting and advancing the upper incisor template.
  99. 99. The soft tissue outline of the upper lip is automatically adjusted through the algorithmic response calculations.
  100. 100. The video portion of the software is adjusted to the prediction outline, simulating a soft-tissue response to the incisor movement.
  101. 101. Simulation of mandibular advancement is accomplished by clicking and dragging the mandibular template forward. The quantitation table supplies the amount of advancement required to achieve ideal over jet and over bite.
  102. 102. Simulation of mandibular advancement is accomplished by clicking and dragging the mandibular template forward.
  103. 103. Once the mandibular template is brought forward to ideal over jet & over bite, the video profile is adjusted to the cephalometric prediction through the “auto-treat” or morph function of the cephalometric software.
  104. 104. See the soft-tissue response
  105. 105. The profile is judged to be still moderately convex, so an advancement genioplasty is simulated by advancing the template of the chin. The figure illustrates the cephalometric outline prediction of a 4 mm anterior movement of chin.
  106. 106. Advancement genioplasty
  107. 107. This image is auto treated.This movement can be greatly influenced by patient direction and desire because there are few functional demands on this movement
  108. 108. The final prediction image now reflects a treatment plan that has corrected the malocclusion and arrived at an esthetically pleasing profile to both patient and clinician. Final projected profile outcome with ceph tracing blinked off
  109. 109. ceph tracing blinked off
  110. 110. The quantity of all osseous and soft-tissue changes are also visualized on the monitor.The ideal face is the goals and target of treatment, and computer serves as a feedback mechanism to view the magnitude of the movements required to achieve the desired outcome and to decide whether these movements are indeed attainable. Overlay of the pre treatment tracing &treatment prediction tracing with the final video projection
  111. 111. superimposition
  112. 112. Close-up view of profile after orthodontic treatment,mandibular advancement,&chin advancement.
  113. 113. After the post- surgical orthodontic therapy is completed and post operative swelling has decreased,the clinician is able to compare the predicted and actual profile results.
  114. 114. VCD ACTUAL
  115. 115. The final occlusal result is an excellent class I relation
  116. 116. PRE VCD POST
  117. 117.
  118. 118.
  119. 119.
  120. 120.
  121. 121. Adolescent prediction Video cephalometric planning is not ineffective in the adolescent case, but the complexities of the facial growth contribute to inaccuracies in prediction. In adults it is very accurate because static nature of dental & soft-tissue relationship.
  122. 122. The factors that contribute to inaccuracies are Skeletal growth patterns are notoriously unpredictable Soft-tissue growth is rarely included in growth projections. Co-operation from children towards treatment is minimal.
  123. 123.
  124. 124. VCD Prediction of profile outcome is only as good as the Cephalometric VTO in the growing patient. The comparison of treatment projection & the final result indicates the current reliability of adolescent prediction.
  125. 125. Medico-legal issues The accuracy of video images are effected by  Honesty of the treatment prediction - mainly as a communicative tool - Prediction should be done which can be achieved  Technical capabilities of clinicians Close communication is required between surgeons, orthodontists,and dentists involved in the case and each member must place faith in other’s capabilities and follow the plan.
  126. 126. Summary of advantages of vcd  A higher level of communication  More precision in this communication  This communication is more effective & less time consuming. Because imaging is more realistic & life-like,the treatment planning process is facilitated for the orthodontist by the following
  127. 127.  Improved visualization of the individual treatment plans.This results in greater precision in planning a desired outcome.  Greater participation by patient’s in helping in the decision making process of their final result.  A mutual template is provided for decision making among patient,orthodontist & oral surgeon.  It reduces the guess work in planning.
  128. 128. In a study by sarver,johnston & matuka(j.o.m.f.s 1988) 90% of patient’s reported that the final result was as good as or better than the projected image. This means that  we are very accurate in predicting.  Our surgeon’s are very good at placing the osteotomies where it is required.
  129. 129. Patient unhappiness may result from  The planner outlines treatment that is clinically unattainable.  The orthodontist or oral surgeon are unable to “deliver the goods” as outlined or planned.
  130. 130. Vendors of software  DIGIGRAPH Dolphin imaging systems,valencia,calif.  PRESCRIPTION PLANNER & PORTRAIT Rx data design Inc,Ooltwah.  QUICKCEPH IMAGE Orthodontic processing,coronado,calif  DENTOFACIAL PLANNER Dento facial software Inc,toronto,canada.  MEASURE Pacific coast software Inc,pasific palisades, calif
  131. 131. OTP Records Orthovision Technologies  ShowCase Dentofacial Software  Vistadent GAC The cost currently $ 12,000-16,000 ( Source: JCO Volume 1995 Oct PETER M. SINCLAIR, DDS, M)
  132. 132. CONCLUSION It is no more that the doctor is the sole decision maker .It is the doctor’s legal and moral responsibility to advice a patient of risk & benefit considerations of contemplated treatment and to present and discuss treatment alternatives and the risk involved in the treatment. The vcd might help as a aid in the process.
  133. 133. Thank you Leader in continuing dental education