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Research Article
Revised

Accuracy of linear measurements obtained from stitched cone beam computed tomography images versus direct skull measurements

[version 2; peer review: 2 approved]
PUBLISHED 02 Mar 2020
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Background: To assess whether the linear measurements obtained from stitched cone beam computed tomography (CBCT) images were as accurate as the direct skull measurements.
Methods: Nine dry human skulls were marked with gutta-percha at reference points to obtain Twenty-two linear measurements on each skull. Ten measurements in the cranio-caudal plane, two measurements in the antero-posterior plane, and ten measurements in the medio-lateral plane. CBCT linear measurements obtained using stitching software were measured and compared with direct skull measurements.
Results: The absolute Dahlberg error between direct linear measurements and linear measurements on stitched CBCT images ranged from (0.07 mm to 0.41 mm). The relative Dahlberg error ranged from (0.2% to 1.8%). Moreover, Intra-class Correlation Coefficient (ICC) ranged from (0.97 to 1.0) indicating excellent agreement.
Conclusion: Stitched CBCT linear measurements were highly comparable to the direct skull measurements using a digital caliper.

Keywords

Cone beam CT, linear measurements, accuracy, direct measurements, field of view, stitched images.

Revised Amendments from Version 1

A new co-author has been added:
Mostafa Mohamed El Dawlatly MSc., MOrth RCS(Ed), PhD, who was involved in setting the measuring protocol on the skulls, taking the study photos and in writing the article manuscript.

To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table.

Introduction

The use of cone beam computed tomography (CBCT) machines in dentistry started in the second half of the 1990s1. Now, CBCT is extensively used in the dental field for implant planning, in endodontics, maxillofacial surgeries and orthodontics2.

In the field of orthodontics, analysis of cephalometric radiographs requires accurate identification of specific landmarks for precise measurements between these landmarks3. As a consequence, the small field of view (FOV) CBCT systems available in small clinics cannot yet satisfy the needs of maxillofacial surgeons or orthodontists4. Thus, visualizing all of these landmarks on the same scan is not always possible5.

In order to compensate for this shortcoming, small FOV images can be scanned and then fused together to produce a single large FOV image. However, there are few data to show whether this fused image is as precise as a single image of the whole area of interest4,6.

Therefore, the aim of the current study was to assess the diagnostic accuracy of stitched CBCT linear measurements versus direct measurements on skulls.

Methods

The current study was conducted on nine dry human skulls obtained from the Anatomy department, Faculty of Medicine, Cairo University to avoid the exposure of living humans to unnecessary radiation doses. 26 anatomical landmarks were identified on each skull (Table 1). Gutta percha cones (GE16121542, META BIOMED) were glued and used as radiopaque markers (Figure 1Figure 3).

Table 1. Showing the twenty-six anatomical landmarks identified on each skull.

Nasion (N)The most anterior median point on the fronto-nasal suture.
Anterior nasal spine (ANS)The most anterior median point (tip) of the anterior nasal spine of the maxilla.
Posterior nasal spine (PNS)The most posterior median point (tip) of the posterior nasal spine of the maxilla.
A -point (A) The point of maximum concavity in the midline of the alveolar process of the maxilla.
B-point (B)The point of maximum concavity in the midline of the alveolar process of the mandible.
Menton (Me)The most inferior midpoint of the chin on the outline of the mandibular symphysis.
Zygomatic foramen (ZYF) R&LA small aperture on the convexity of the malar surface of the zygomatic bone near its center.
Condyle (Co) R&LThe most superior median point of the right and left condylar head.
Mandibular gonion (Go) R&LMost posterior and inferior point of the curve between the body and ascending ramus on the right
and left sides of the mandible.
Medial orbital wall (MOR) R&LPoint on the middle of the medial wall of the right and left orbits.
Lateral orbital wall (LOR) R&LPoint on the middle of the lateral wall of the right and left orbits.
Infra-orbital foramen (ORF) R&LForamen located below the infra-orbital margin of the right and left orbits.
Greater palatine foramen (GP) R&LAn aperture on the right and left postero-lateral aspects of the hard palate.
Mental foramen (MF) R&LAn aperture on the buccal surface of the mandible in the area of the mandibular premolars teeth on
the right and left sides.
Anterior ramus (AR) R &LPoint on the middle of the anterior border of the right and left ramus.
Posterior ramus (PR) R&LPoint on the middle of the posterior border of the right and left ramus.
56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure1.gif

Figure 1. A photograph showing the frontal aspect of the skull.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure2.gif

Figure 2. A photograph showing the lateral aspect of the skull.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure3.gif

Figure 3. A photograph showing the skull base.

22 linear measurements were taken and recorded using a high precision sliding digital caliper (6400192, Allendale Electronics Ltd, Hertfordshire, UK). Ten measurements in the cranio-caudal plane (Table 2), two measurements in the antero-posterior plane (Table 3), and ten measurements in the medio-lateral plane (Table 4). 22 direct linear measurements were measured and were considered to be the gold standard in the study (Figure 4Figure 6).

Table 2. Showing cranio-caudal linear measurements.

N-ANSNasion to anterior nasal spine.
N-ANasion to A-point.
N-BNasion to B-point.
N-MeNasion to menton.
ANS-AAnterior nasal spine to A-point.
ANS-MeAnterior nasal spine to menton.
B-MeB-point to menton.
ORF(R)-MF(R)Right infra-orbital foramen to right mental foramen.
ZYF(R)-MF(R)Right zygomatic foramen to right mental foramen.
CO(R)-GO(R)Right condyle to right gonion.

Table 3. Showing antero-posterior linear measurements.

ANS-PNSAnterior nasal spine to posterior nasal spine.
AR(R)-PR(R)Right anterior ramus to right posterior ramus.

Table 4. Showing medio-lateral linear measurements.

CO(R)-CO(L)Right condyle to left condyle.
GO(R)-GO(L)Right gonion to left gonion.
GP(R)-GP(L)Right greater palatine foramen to left greater palatine foramen.
ORF(R)-ORF(L)Right infra-orbital foramen to left infra-orbital foramen.
ZYF(R)-ZYF(L)Right zygomatic foramen to left zygomatic foramen.
MOR(R)-MOR(L)Right medial orbital wall to left medial orbital wall.
LOR(R)-LOR(L)Right lateral orbital wall to left lateral orbital wall.
MF(R)-MF(L)Right mental foramen to left mental foramen.
AR(R)-AR(L)Right anterior ramus to left anterior ramus.
PR(R)-PR(L)Right posterior ramus to left posterior ramus.

R – right, L - left

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure4.gif

Figure 4. A photograph showing direct linear measurement from Nasion to Anterior nasal spine.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure5.gif

Figure 5. A photograph showing direct linear measurement from right Zygomatic foramen to right Mental foramen.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure6.gif

Figure 6. A photograph showing direct linear measurement from right Medial orbital wall to left Medial orbital wall.

For soft tissue simulation, the skulls were covered with 20 layers of pink modelling wax (1mm thick each) (Tenatex eco, Kemdent) to achieve an average of 14–16 mm wax thickness7.

The skulls were stabilized in the Planmeca ProMax 3D Mid CBCT machine using a wooden stand passing through the foramen magnum and were oriented using the laser beams (Figure 7). Three consecutive FOVs were scanned: two scans each of the size 160 ×60 mm (single arch) for the mandible and the maxilla separately (Figure 8 and Figure 9) and one scan with a FOV size 200 ×100 mm for the upper third of the face (Figure 10). Each one of the three FOVs was scanned separately using a voxel resolution 0.2 mm, 90 kVp and 10 mA, then stitching was performed using Romexis software (Planmeca Romexis Viewer Launcher 4.5.0.R) creating one large volume (Figure 11). After completion of the stitching procedure the linear measurements were obtained from the stitched CBCT images for a later comparison with the gold standard (Figure 12 and Figure 13).

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure7.gif

Figure 7. A photograph showing the skull centralized within the CBCT machine in the proper position.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure8.gif

Figure 8. First field of view showing the mandible.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure9.gif

Figure 9. Second field of view showing the maxilla.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure10.gif

Figure 10. Third field of view showing the upper third of the face, orbits, frontal bone.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure11.gif

Figure 11. The final image showing the stitched three small fields of view into a single large one.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure12.gif

Figure 12. Coronal cut showing linear measurement of Orbital foramen (right)-Mental foramen (right) on a stitched image.

56ee96a6-d46e-47eb-b98b-b06d7190a1b0_figure13.gif

Figure 13. Coronal cut showing linear measurement of Medial orbital wall (right)-Medial orbital wall (left) on a stitched image.

Statistical analysis

Statistical analysis was performed on SPSS (version 17). For assessment of the agreement between all measurements with the reference method, Dahelberg error (DE), and Relative Dahelberg Error (RDE) were used together with Intra-class Correlation Coefficients (ICC) including the 95% confidence limits of the coefficient calculated assuming analysis of variance two-way mixed model ANOVA with absolute agreement on SPSS. To measure and quantify the size of the differences, Bland and Altman 95% confidence Limits of Agreements (LOA) were applied.

Results

Error assessment of linear measurements conducted on stitched CBCT images versus direct skull measurements (the gold standard) (Table 5)

The results of the current study showed that, the difference between the mean of the direct linear measurements and the mean of the linear measurements conducted on the stitched CBCT images ranged from (-0.25 mm to 0.5 mm), the positive and negative values indicating that there was no obvious pattern of over or underestimation in the stitched CBCT measurements.

Table 5. Comparing direct linear measurements and measurements conducted on stitched CBCT images.

Bland &
Altman Limits
of Agreement
(LOA)
Intra-class Correlation
Coefficient
Linear
Measurements
Direct/
Stitched
MeanSDDahlberg
Error
(DE)
Relative
Dahlberg
Error
(RDE)
Mean of
Difference
(Reference
- Stitched)
SD of the
Difference
95%confidence
limits
95%confidence
limits
LowerUpperICCLowerUpper
N-ADirect
Reference
56.714.350.210.4%-0.110.30-0.700.470.9990.9951.000
Stitched56.824.35
N-ANSDirect
Reference
49.854.110.250.5%-0.150.33-0.810.500.9980.9921.000
Stitched50.004.20
N-MeDirect
Reference
96.919.440.270.3%0.210.33-0.450.861.0000.9981.000
Stitched96.709.54
N-BDirect
Reference
77.917.560.290.4%-0.250.34-0.920.420.9990.9951.000
Stitched78.167.51
ANS-ADirect
Reference
7.281.620.091.3%-0.090.10-0.290.100.9980.9831.000
Stitched7.371.63
ANS-PNSDirect
Reference
52.283.390.090.2%0.020.14-0.250.301.0000.9981.000
Stitched52.263.39
ANS-MeDirect
Reference
46.956.520.230.5%0.000.34-0.660.670.9990.9971.000
Stitched46.956.59
B-MeDirect
Reference
18.883.130.150.8%0.180.12-0.060.420.9990.9491.000
Stitched18.703.17
ORF(R)-ORF(L)Direct
Reference
53.015.540.150.3%-0.040.23-0.480.411.0000.9981.000
Stitched53.045.43
MOR(R)-MOR(L)Direct
Reference
22.941.890.411.8%0.500.32-0.131.120.9740.3180.996
Stitched22.451.67
LOR(R)-LOR(L)Direct
Reference
96.813.860.220.2%0.050.32-0.580.680.9980.9931.000
Stitched96.763.88
ZYF(R)-ZYF(L)Direct
Reference
96.956.180.170.2%0.110.22-0.330.551.0000.9981.000
Stitched96.856.26
GP(R)-GP(L)Direct
Reference
31.602.690.150.5%-0.070.21-0.490.350.9980.9931.000
Stitched31.672.63
ORF(R)-MF(R)Direct
Reference
46.615.080.220.5%0.030.33-0.620.680.9990.9961.000
Stitched46.595.14
ZYF(R)-MF(R)Direct
Reference
57.566.700.150.3%-0.060.22-0.490.371.0000.9991.000
Stitched57.626.83
CO(R)-CO(L)Direct
Reference
101.524.080.230.2%-0.030.34-0.690.630.9980.9931.000
Stitched101.553.91
GO(R)-GO(L)Direct
Reference
94.198.060.270.3%0.070.40-0.720.860.9990.9981.000
Stitched94.128.11
CO(R)-GO(R)Direct
Reference
58.526.650.130.2%-0.010.20-0.400.381.0000.9991.000
Stitched58.546.64
AR(R)-AR(L)Direct
Reference
83.312.710.300.4%0.040.45-0.850.930.9940.9740.999
Stitched83.272.87
MF(R)- MF(L)Direct
Reference
44.720.950.150.3%-0.100.20-0.490.290.9870.9450.997
Stitched44.820.95
PR(R)-PR(L)Direct
Reference
96.325.300.380.4%0.300.48-0.641.240.9970.9860.999
Stitched96.025.14
AR(R)-PR(R)Direct
Reference
33.072.480.070.2%0.040.09-0.130.211.0000.9991.000
Stitched33.032.48

N – Nasion, ANS - Anterior nasal spine, PNS - Posterior nasal spine, A – A point, B – B point, Me – Menton, ZYF - Zygomatic foramen, Co – Condyle, GO – Mandibular gonion, MOR – Medial orbital wall, LOR – Lateral orbital wall, ORF – infra-orbital foramen, GP – Greater palatine foramen, MF – Mental foramen, AR – Anterior ramus, PR – Posterior ramus, R – right, L - left

Mean absolute difference of all measurements was (0.11± 0.12 mm). Bland and Altman Lower limit of agreement ranged from (-0.92 mm to -0.06 mm). Bland and Altman Upper limit of agreement ranged from (0.1 mm to 1.24 mm).

The absolute Dahlberg error between direct linear measurements and linear measurements on stitched CBCT images ranged from (0.07 mm to 0.41 mm). The relative Dahlberg error ranged from (0.2% to 1.8%). Moreover, Intra-class Correlation Coefficient (ICC) ranged from (0.97 to 1.0). (Table 5).) indicating excellent agreement.

Discussion

The smaller the scan FOV, the higher the spatial resolution of the image8. Stitching of small CBCT images to create a large image can be very useful to collect the needed cranio-maxillofacial data with small FOV machines9. Increasing the FOV can be done by automatically fusing up to three small FOVs to obtain a larger FOV10.

CBCT ‘‘Stitching’’ option could be useful but whether it is precise enough to obtain accurate and reliable measurements remains doubtful11. Assessing the accuracy of stitched CBCT measurements is infrequently mentioned in current literature, as in the studies conducted by Kopp and Ottl; 2010, Kim et al.; 2012, Egbert et al.; 2015, and Srimawong et al.; 20155,8,10,12.

The results of the current study showed that the relative Dahlberg error ranged from 0.2% to a maximum of 1.8%. Consequently, the error was considered small and clinically non-significant as the measurement error in craniofacial imaging is considered clinically acceptable up till the value of 5%13,14.

The results of the current study go in agreement with the study performed by Srimawong et al.; 2015 on 10 dry human mandibles12. Their results showed that, the mean absolute differences between direct measurements and stitched CBCT measurements for vertical and horizontal distances were (0.27±0.24 mm) and (0.34±0.27 mm), respectively. Their results showed that the stitched CBCT measurements were highly accurate comparable to the direct measurements.

In support of the present results, Egbert et al.; 20158 research revealed that the mean difference between the direct linear measurements and the stitched CBCT measurements was 0.34 mm with a 95% confidence interval of (0.24 to 0.44 mm). They concluded that the precision of stitched CBCT measurements allow accurate construction of implant surgical stents.

Moreover, the results of Kopp and Ottl; 201010 further agree with those obtained from the current study. They used an automated method to increase the FOV of CBCT images by stitching three small FOV volumes to obtain a larger FOV one. They concluded that, the stitching software was accurate in the obtained linear measurements.

On the same line of agreement, a study was performed by Kim et al.; 20125 to investigate whether images of skulls obtained by both manual and automatic stitching of three CBCT images, provided accurate measurements as those obtained by multidetector computed tomography (MDCT). The results showed that the mean difference between automatically stitched CBCT images and the reference images ranged from (-0.8944 mm to -1.0628 mm).

Conclusion

Stitched CBCT linear measurements were highly comparable to the direct skull measurements. However, a percent of error should be expected from CBCT-derived measurements.

Data availability

Underlying data is available from Open Science Framework

OSF: Dataset 1. Accuracy of Linear Measurements Obtained from Stitched Cone Beam CT Images Versus Direct Skull Measurements https://doi.org/10.17605/OSF.IO/SUTWK15

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Hamed DAF, El Dawlatly MM, El Dessouky SH and Hamdy RM. Accuracy of linear measurements obtained from stitched cone beam computed tomography images versus direct skull measurements [version 2; peer review: 2 approved]. F1000Research 2020, 8:166 (https://doi.org/10.12688/f1000research.17751.2)
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
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Reviewer Report 28 Apr 2020
Luca Fiorillo, Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy 
Approved
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Please improve conclusion section with ... Continue reading
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Fiorillo L. Reviewer Report For: Accuracy of linear measurements obtained from stitched cone beam computed tomography images versus direct skull measurements [version 2; peer review: 2 approved]. F1000Research 2020, 8:166 (https://doi.org/10.5256/f1000research.24950.r60778)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 13 Nov 2019
Pathawee Khongkhunthian, Center of Excellence for Dental Implantology, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand 
Approved
VIEWS 10
The comparative study between direct measurement of the skull and the stitching CBCT data obtained from different view had been well designed and performed. The statistical analysis are appropriate and sufficient to make the conclusion. The study showed the accuracy of stitching ... Continue reading
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Khongkhunthian P. Reviewer Report For: Accuracy of linear measurements obtained from stitched cone beam computed tomography images versus direct skull measurements [version 2; peer review: 2 approved]. F1000Research 2020, 8:166 (https://doi.org/10.5256/f1000research.19409.r55480)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 12 Aug 2019
Luca Fiorillo, Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy 
Approved with Reservations
VIEWS 8
This study is very interesting, and having assessed the reliability of radiographic examinations is very useful for clinical practice.

We should only understand, as a future perspective, the differences between the different devices used, or between the different ... Continue reading
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Fiorillo L. Reviewer Report For: Accuracy of linear measurements obtained from stitched cone beam computed tomography images versus direct skull measurements [version 2; peer review: 2 approved]. F1000Research 2020, 8:166 (https://doi.org/10.5256/f1000research.19409.r52211)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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