One Step before 3D Printing\u2014Evaluation of Imaging Software Accuracy for 3-Dimensional Analysis of the Mandible: A Comparative Study Using a Surface-to-Surface Matching Technique

Abstract: The accuracy of 3D reconstructions of the craniomaxillofacial region using cone beam computed tomography (CBCT) is important for the morphological evaluation of specific anatomical structures. Moreover, an accurate segmentation process is fundamental for the physical reconstruction of the anatomy (3D printing) when a preliminary simulation of the therapy is required. In this regard, the objective of this study is to evaluate the accuracy of four dierent types of software for the semiautomatic segmentation of the mandibular jaw compared to manual segmentation, used as a gold standard. Twenty cone beam computed tomography (CBCT) with a manual approach (Mimics) and a semi-automatic approach (Invesalius, ITK-Snap, Dolphin 3D, Slicer 3D) were selected for the segmentation of the mandible in the present study. The accuracy of semi-automatic segmentation was evaluated: (1) by comparing the mandibular volumes obtained with semi-automatic 3D rendering and manual segmentation and (2) by deviation analysis between the two mandibular models. An analysis of variance (ANOVA) was used to evaluate dierences in mandibular volumetric recordings and for a deviation analysis among the dierent software types used. Linear regression was also performed between manual and semi-automatic methods. No significant dierences were found in the total volumes among the obtained 3D mandibular models (Mimics = 40.85 cm3, ITK-Snap = 40.81 cm3, Invesalius = 40.04 cm3, Dolphin 3D = 42.03 cm3, Slicer 3D = 40.58 cm3). High correlations were found between the semi-automatic segmentation and manual segmentation approach, with R coecients ranging from 0,960 to 0,992. According to the deviation analysis, the mandibular models obtained with ITK-Snap showed the highest matching percentage (Tolerance A = 88.44%, Tolerance B = 97.30%), while those obtained with Dolphin 3D showed the lowest matching percentage (Tolerance A = 60.01%, Tolerance B = 87.76%) (p < 0.05). Colour-coded maps showed that the area of greatest mismatch between semi-automatic and manual segmentation was the condylar region and the region proximate to the dental roots. Despite the fact that the semi-automatic segmentation of the mandible showed, in general, high reliability and high correlation with the manual segmentation, caution should be taken when evaluating the morphological and dimensional characteristics of the condyles either on CBCT-derived digital models or physical models (3D printing)

Morphological Variation of the Mandible in the Orthognathic Population—A Morphological Study Using Statistical Shape Modelling

The aim of this study was to investigate the value of 3D Statistical Shape Modelling for orthognathic surgery planning. The goal was to objectify shape variations in the orthognathic population and differences between male and female patients by means of a statistical shape modelling method. Pre-operative CBCT scans of patients for whom 3D Virtual Surgical Plans (3D VSP) were developed at the University Medical Center Groningen between 2019 and 2020 were included. Automatic segmentation algorithms were used to create 3D models of the mandibles, and the statistical shape model was built through principal component analysis. Unpaired t-tests were performed to compare the principal components of the male and female models. A total of 194 patients (130 females and 64 males) were included. The mandibular shape could be visually described by the first five principal components: (1) The height of the mandibular ramus and condyles, (2) the variation in the gonial angle of the mandible, (3) the width of the ramus and the anterior/posterior projection of the chin, (4) the lateral projection of the mandible’s angle, and (5) the lateral slope of the ramus and the inter-condylar distance. The statistical test showed significant differences between male and female mandibular shapes in 10 principal components. This study demonstrates the feasibility of using statistical shape modelling to inform physicians about mandible shape variations and relevant differences between male and female mandibles. The information obtained from this study could be used to quantify masculine and feminine mandibular shape aspects and to improve surgical planning for mandibular shape manipulations.</p

3D mandibular superimposition: Comparison of regions of reference for voxel-based registration

The aim was to evaluate three regions of reference (Björk, Modified Björk and mandibular Body) for mandibular registration testing them in a patients' CBCT sample.Mandibular 3D volumetric label maps were built from CBCTs taken before (T1) and after treatment (T2) in a sample of 16 growing subjects and labeled with eight landmarks. Registrations of T1 and T2 images relative to the different regions of reference were performed, and 3D surface models were generated. Seven mandibular dimensions were measured separately for each time-point (T1 and T2) in relation to a stable reference structure (lingual cortical of symphysis), and the T2-T1 differences were calculated. These differences were compared to differences measured between the superimposed T2 (generated from different regions of reference: Björk, Modified Björk and Mandibular Body) over T1 surface models. ICC and the Bland-Altman method tested the agreement of the changes obtained by nonsuperimposition measurements from the patients' sample, and changes between the overlapped surfaces after registration using the different regions of reference.The Björk region of reference (or mask) did work properly only in 2 of 16 patients. Evaluating the two other masks (Modified Björk and Mandibular body) on patients' scans registration, the concordance and agreement of the changes obtained from superimpositions (registered T2 over T1) compared to results obtained from non superimposed T1 and T2 separately, indicated that Mandibular Body mask displayed more consistent results.The mandibular body mask (mandible without teeth, alveolar bone, rami and condyles) is a reliable reference for 3D regional registration

A User-Friendly Protocol for Mandibular Segmentation of CBCT Images for Superimposition and Internal Structure Analysis

Background: Since cone-beam computed tomography (CBCT) technology has been widely adopted in orthodontics, multiple attempts have been made to devise techniques for mandibular segmentation and 3D superimposition. Unfortunately, as the software utilized in these methods are not specifically designed for orthodontics, complex procedures are often necessary to analyze each case. Thus, this study aimed to establish an orthodontist-friendly protocol for segmenting the mandible from CBCT images that maintains access to the internal anatomic structures. Methods: The “sculpting tool” in the Dolphin 3D Imaging software was used for segmentation. The segmented mandible images were saved as STL files for volume matching in the 3D Slicer to validate the repeatability of the current protocol and were exported as DICOM files for internal structure analysis and voxel-based superimposition. Results: The mandibles of all tested CBCT datasets were successfully segmented. The volume matching analysis showed high consistency between two independent segmentations for each mandible. The intraclass correlation coefficient (ICC) analysis on 20 additional CBCT mandibular segmentations further demonstrated the high consistency of the current protocol. Moreover, all of the anatomical structures for superimposition identified by the American Board of Orthodontics were found in the voxel-based superimposition, demonstrating the ability to conduct precise internal structure analyses with the segmented images. Conclusion: An efficient and precise protocol to segment the mandible while retaining access to the internal structures was developed on the basis of CBCT images. © 2021 by the authors. Licensee MDPI, Basel, Switzerland

Contributions to the three-dimensional virtual treatment planning of orthognathic surgery

Orientadores: José Mario De Martino, Luis Augusto PasseriTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Engenharia Elétrica e de ComputaçãoResumo: A tecnologia mais recente à disposição da Cirurgia Ortognática possibilita que o diagnóstico e o planejamento do tratamento das deformidades dentofaciais sejam realizados sob uma representação virtual tridimensional (3D) da cabeça do paciente. Com o propósito de contribuir para o aperfeiçoamento desta tecnologia, o trabalho apresentado nesta tese identificou e tratou quatro problemas. A primeira contribuição consistiu na verificação da validade da hipótese de que a mudança de definição do plano horizontal de Frankfort não produz diferenças de medição clinicamente relevantes quando sob indivíduos cujos crânios são consideravelmente simétricos. Os resultados da análise realizada no contexto deste tese indicam que, ao contrário do que se presumia, a hipótese é falsa. A segunda contribuição consistiu na extensão do método de análise cefalométrica de McNamara para que ele pudesse produzir valores 3D. Ao contrário de outros métodos de análise cefalométrica 3D, a extensão criada produz valores verdadeiramente 3D, não perde as informações do método original e preserva as definições geométricas originais das linhas e planos cefalométricos. A terceira contribuição consistiu a) no estabelecimento de normas cefalométricas para brasileiros adultos de ascendência europeia, a partir de imagens de tomografia computadorizada de feixe cônico, que produz uma imagem craniofacial mais precisa e confiável do que a telerradiografia; e b) na avaliação de dimorfismo sexual, para a identificação de características anatômicas diferenciadas entre homens e mulheres desta população. A quarta e última contribuição consistiu na automatização da principal etapa da tecnologia em questão, na qual o cirurgião executa o reposicionamento dos segmentos ósseos maxilares no crânio. O método criado é capaz de corrigir automaticamente os problemas dentofaciais mais comuns tratados pela Cirurgia Ortognática, que envolvem maloclusão esquelética, assimetria facial e discrepância de maxilares. Todas as contribuições deste trabalho foram publicadas em periódicos internacionais do campo da Odontologia e afinsAbstract: The latest technology available for orthognathic surgery allows the diagnosis and treatment planning of dentofacial deformities based on a three-dimensional (3D) virtual representation of the patient's head. In order to contribute to the improvement of this technology, the work presented in this thesis identified and treated four problems. The first contribution consisted in testing the validity of the hypothesis that changing the definition of the Frankfort horizontal plane does not produce clinically relevant measurement differences for subjects whose skulls are considerably symmetrical. The results of the analysis performed in this thesis indicate that, contrary to what was presumed, the hypothesis is false. The second contribution is an extension of the McNamara's method of cephalometric analysis to produce 3D values. Unlike other methods of 3D cephalometric analysis, the extension produces true 3D values, does not lose information captured by the original method, and preserves the original geometric definitions of the cephalometric lines and planes. The third contribution consisted in a) establishing cephalometric norms for Brazilian adults of European descent, based on images from cone-beam computed tomography, which produce a more accurate and reliable craniofacial image than cephalometric radiography; and b) evaluating sexual dimorphism, for the identification of distinct anatomic features between males and females of this population. The fourth contribution consisted in automating the main stage of the technology in question, in which the surgeon performs the positioning of jaw bone segments in the skull. The created method is able to automatically correct the most common dentofacial problems treated by orthognathic surgery, which involves skeletal malocclusion, facial asymmetry, and jaw discrepancy. The contributions of this work were published in international journals of the field of Dentistry and relatedDoutoradoEngenharia de ComputaçãoDoutor em Engenharia ElétricaCAPE

Diagnosis and Quantitative Assessment of Mandibular Asymmetry Using CBCT Image Volumes

Objectives: To compare two methods of measuring mandibular asymmetry. The first method uses mirroring of the mandible in the midsagittal plane; the second uses arbitrary mirroring of the mandible and registration on the cranial base. Methods: Surface models were constructed from CBCT scans of 50 patients with asymmetry. For the first approach, a midsagittal plane was defined for each patient as the plane passing through Nasion, ANS, and Basion. Mirrors for both halves of the mandible were created. The second approach was to mirror each model on an arbitrary plane. Both original and arbitrarily mirrored images were registered on the cranial base. Surface distances between hemimandibles and mirrors were calculated for nine regions. Results: There was no statistically significant difference between the mean surface distance measurements obtained with the two approaches, and comparing both halves in most areas. Conclusion: Both mirroring techniques provided similarquantification of mandibular asymmetry in this cohort

Similarity index for intuitive assessment of three-dimensional facial asymmetry

Evaluation of facial asymmetry generally involves landmark-based analyses that cannot intuitively assess differences in three-dimensional (3D) stereoscopic structures between deviation and non-deviation sides. This study tested a newly developed similarity index that uses a mirroring technique to intuitively evaluate 3D mandibular asymmetry, and characterised the resulting lower facial soft tissue asymmetry. The similarity index was used to evaluate asymmetry before and after surgery in 46 adult patients (27 men, 19 women; age, 22 ± 4.8 years) with skeletal Class III malocclusion and facial asymmetry who underwent conventional bimaxillary orthognathic surgery. Relative to the midsagittal plane used as the reference plane, the non-overlapping volume of the mandible significantly decreased, and the similarity index significantly increased after surgery. Similarity indexes of the mandible and lower facial soft tissue were strongly negatively correlated with non-overlapping volumes of each measurement. Differences in bilateral hemi-mandibular and hemi-lower facial soft tissue surface and volume measurements before surgery were significantly negatively correlated with similarity indexes of the mandible before and after surgery. This newly developed similarity index and non-overlapping volume using a mirroring technique can easily and intuitively evaluate overall 3D morphological discrepancies, especially 3D mandibular asymmetry, before and after surgery in skeletal Class III patients with facial asymmetry.ope