SMGr up Review Article

SM Dentistry Recent Advancements in Diagnostic Aids

Journal in Orthodontics - A Review
Ashish Kakadiya1, Ragni Tandon2, Aftab Azam2, Rohit Kulshrestha3* and Madhvi
Bhardwaj4
1
Consulting Orthodontist, Private Practice Surat, India
2
Department of Orthodontics and Dentofacial Orthopedics, Saraswati Dental College, India
3
Consulting Orthodontist, Private Practice, Mumbai, India
4
Department of Orthodontics and Dentofacial Orthopedics, Career PG Institute of Dental Sciences, India

Article Information Abstract

Received date: Aug 05, 2017 Every medical, dental and surgical procedure is solely based on the diagnosis of the underlying pathology
Accepted date: Aug 30, 2017 or disorder. In recent times there has been a tremendous advancement in scientific technology which has helped
dental practitioners all over the world. The use of computers in cephalometry has made it easier to view and
Published date: Sep 05, 2017 measure various readings. Computer aided design and computer aided manufacturing have increased the
accuracy and quality of all dental materials. In the field of Orthodontics, there have been many advances. This
*Corresponding authors article summarizes the recent advancements in diagnostic aids in Orthodontics which has helped revolutionize
treatment planning for the Orthodontic fraternity.
Rohit Kulshrestha, Consulting
Orthodontist, Private Practice,
Mumbai, India, Tel: +918601462462; Introduction
Email: kulrohit@gmail.com Recent advances in diagnostic aids address a special aspect of orthodontic diagnosis and
Distributed under Creative Commons treatment planning that has become increasingly, important in our litigious society [1]. Successful
CC-BY 4.0 orthodontic treatment is dependent on the disciplined approach to record taking and diagnosis as
well as careful monitoring of progress in treatment, an inadequate record may be reflective of a poor
Keywords CBCT; Digital models; standard of treatment. The essentials for orthodontic records are a diagnostic report supported by
Diagnostic aids study models, radiographs and photographs to establish the condition of the case before treatment
and to record progress during treatment. The problem oriented dental records significantly aids
in making the appropriate diagnosis. There is a significant improvement over the morphologically
oriented diagnostic methods. The orthodontist’s job is to fit the pieces of the human craniofacial
complex puzzle together. The expected outcome of this endeavour is a harmonious rearrangement
that is not only functional but also aesthetically pleasing. Clearly, this process must take into account
the relationships in all three special axes. Oddly enough, while orthodontic treatment affects all
three dimensions, many of the current tools of diagnosis employ only a Two Dimensional (2D)
representation of the patient. The two goals of orthodontic treatment (function and aesthetics) are
dynamic entities. The statically occluded teeth are of limited value, though they might look good in
the form of a plaster cast. This is no different than the good-looking and the not so-good-looking,
giving at least one pose to the photographer where they would appear aesthetically pleasing. In the
absence of a system where function and aesthetics can be assessed, both the orthodontist and the
patient are left to imagines or fantasize, rather than know, what the treatment outcome might be [2].
The development of integrated 3D tools for diagnosis and treatment planning is one of the most
exciting developments in orthodontics as the specialty moves into the 21st century. The development
of Computed Tomography (CT) and Three-Dimensional (3D) reconstruction in the 1970’s brought
about a revolution in diagnostic radiology because cross-sectional imaging became possible. By
the late 1980’s, 3D reconstruction algorithms were more optimized, and three-dimensional image
reformatting of standard 2D CT data (3D CT) became an often used tool to provide the radiologist
and surgeon with readily recognizable images of complex anatomic structures such as the skull. These
techniques can exactly record and represent the life-size and shape of the object. Three-dimensional
visualization with proper computer software and environment can be used for diagnosis, surgical
planning, and simulation of operation. Developing such a computer system naturally combines
knowledge from medicine, dentistry, biomedical engineering and computer science [3].
The practice of orthodontics has been transformed by the computer revolution of the 1990’s.
Digital orthodontics has created a paradigm shift in practice management. The orthodontic practice
of the 1970’s and 1980’s can be seen in high contrast to the dynamic practices of the new millennium.
With treatment records always at the orthodontist finger tips, orthodontic treatment has streamlined
and patient management has reached levels of sophistication never before possible. The internet
and the development of high-speed communication modalities have enabled group practices, with
multiple locations, to access records in outlying locations electronically. This paradigm shift will

OPEN ACCESS How to cite this article Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent
Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
ISSN: 2575-7776
SMGr up Copyright  Kulshrestha R

propel orthodontics well into the future [4]. As computers became image quality than by using higher settings. The patient’s effective
more dynamic and reliable, orthodontic practitioners started to use exposure from a resultant CBCT is as low as 45 µSv to as high as 650
computers unique strengths mostly to help in diagnosis and treatment µSv. Full mouth radiographs produce an exposure of 150 µSv and a
planning. The key element in orthodontic treatment remains a skilled round trip from Tokyo to Paris is about 135 µSv of exposure. The
orthodontic specialist with an understanding of the biological and ADA Council on scientific affairs recommends the use of techniques
biomechanical knowledge base that our specialty has painstakingly that would reduce the amount of radiation received during dental
acquired in more the 100 years of collective experience in treatment radiography known as the ALARA principle (as low as reasonably
and research [5]. The purpose of this article was to review the recent achievable). This includes taking radiographs based on the patient
diagnostic aids which help the Orthodontist in treatment planning. needs, using the fastest film compatible with the diagnostic task,
collimating the size of the beam to as close the size of the film as
Cone Beam Computed Tomography feasible and using lead aprons and thyroid shields.
Craniofacial CBCT were developed to counter some of the Digital Cephalometry
limitations of conventional CT scanning devices. In craniofacial
CBCT the object to be evaluated is captured as the radiation falls onto In 1922, Pacini described a rather primitive method for
a two-dimensional retractor. This simple difference allows a single standardization of radiographic imaging of the head. He
rotation of the radiation source to capture an entire region of interest recommended positioning of the subject at a fixed distance of 2m from
as compared to conventional CT device where multiple slices are the x-ray source with a film cassette fixed to the head with a wrapping
stacked to obtain a complete image. The cone beam also produces a of gauze bandages [8,9]. Almost a decade later in 1931, Broadbent
more focused beam and considerably less scatter radiation compared and Hoffarth (The United States and Germany) simultaneously
to conventional fan shaped CT devices (Figure 1). published their own methods of obtaining standardized lateral head
radiographs. Their methods published in the Angle Orthodontist
This significantly increases x-ray utilization and reduces the in 1937, introduced the field of cephalometry to the orthodontic
x-ray tube capacity required for volumetric scanning. It is said that community.
radiation exposure is 20% of conventional CT or equivalent to full
Cephalometry is a vital tool in orthodontic for evaluation of
mouth peri-apical radiographic exposure [5].
craniofacial complex, determination of morphology and growth,
Advantages of CBCT diagnosis of anomalies forecasting future relationship, planning
treatment and evaluating the results of growth and effects of treatment.
• Less cost
Cephalometrics remains the only quantitative method that permits
• Smaller in size investigation and examination of the spatial relationship between
both cranial and dental structures. The lateral cephalogram provide
• Exposure chamber (head) is custom built and reduces the amount information regarding skeletal, dental, and soft tissue morphology as
of radiation well as relationship between these structures [10].
• Images are comparable to conventional CT and are displayed as
full head view, as skull View or as regional components [6,7].
Clinical Applications in Orthodontics
With CBCT Orthodontists have many images that are not
possible with conventional radiographic measures.
• Impacted teeth and oral abnormalities
• Airway analysis
• Assessment of alveolar bone height and volume
• TMJ morphology
• Lateral and frontal Cephalogram views
• Skeletal views
• Facial analysis
• 3D review of dentition [8]
Radiation Exposure
CBCT provides three-dimensional images with up to four times
less radiation than a conventional CT scan. The resultant radiation
is dependent on the settings used (Kvp and mA). The use of lower
mA and/or collimation are some of the ways to reduce the amount
Figure 1: CBCT Machine.
of radiation the patient receives, but at the same time produces lower

Citation: Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent

Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
Page 2/8
SMGr up Copyright  Kulshrestha R

The use of lateral cephalograms in research includes - Factors to be considered before going to purchase software are -
• Quantifying craniofacial parameters in individuals as well as a • Facility of integration of photographs and study models
population of individuals
• Windows based system available
• Distinguishing normal from abnormal
• DICOM compatibility
• Comparing treated samples to untreated controls
• Lateral as well as posterio-anterior analysis should be possible
• Differentiating populations as homogenous or mixed, and
Softwares Developed in India
assessing the change of pattern over time
Digiceph
Since its advent in 1931, conventional cephalometry has
remained unchanged. Digital radiography has been accepted in the Method for computerized digitization analysis and
dental community, but high cost delayed their progress. Recently superimposition
with the development of cost effective radiography (extra oral)
and increased utilization of computers in orthodontics has made • 13 cephalometric analysis
digital cephalometric imaging a viable option. The paradigm shift • Developed by the center for Bio-Medical Engineering, IIT Delhi
is occurring in orthodontics from the widely accepted film based to and Dept of Dental Surgery AIIMS
digital cephalometry. The methodology and various techniques for
Digital Imaging and Communications in Medicine (DICOM)
the development of digital cephalograms are the same procedure
as described earlier for digital radiography. To accept this scientific American College of Radiology (ACR) and the National
description various studies are being carried out to accept the Electrical Manufacturers Association (NEMA) formed a joint
reliability of these digital cephalograms (Figure 2). committee in order to create a standard method for transmission of
Rudolph et al. [11] compared the reliability of digital and medical images and their associated information. DICOM defined
conventional cephalometric radiographs in terms of landmark information standardized not only for images but also for patients,
identification error. They concluded similar reproducibility and students, reports and other data groupings. With the enhancement
made in DICOM (version 3.0) came the development and expansion
precision in landmark identification using both direct digital and
of picture archiving and communication system and its interfacing
conventional lateral cephalometric head films. Heiko vesser et al.
medical information systems.
[12] studied and compared the radiation exposure and dose between
conventional cephalometry and digital cephalometry. They concluded Digital Study Models
that digital cephalometric radiography cuts the radiation dose in
Study models have long been an essential part of the orthodontic
half compared with the conventional screen film technique and
process. They have traditionally been cast out of either plaster or
that digital cephalometry is more advantageous than conventional
stone and have served two main purposes:
cephalometry in that perspective. Jia Kuing Liu et al. [13] studied the
accuracy of computerized identification of landmarks using various • To provide information for diagnosis and treatment planning
angular and linear measurements. They concluded that computerized
• To provide a 3D record of the original malocclusion, any stages
identification of certain landmarks is questionable and further studies
during correction and outcome of the treatment [15,16].
are needed to confirm their accuracy. Geelen et al. [14] studied the
reproducibility of cephalometric landmarks on conventional film, Although study models are almost indispensable to the
hard copy and monitor displayed images obtained by a storage orthodontist, because they are cast in plaster or stone, they do have a
phosphor technique. They concluded that the there was no clinically number of drawbacks in terms of:
significant difference in landmark identification among the various
methods.
A plethora of software’s is available to clinician to choose from -
• Vistadent
• Dolphin
• Quick ceph
• Dentofacial Planner
• Vixwin software
• Dr ceph
• Ortho plan
• Ceph x
Figure 2: Digital Cephalometry Image.
• Orthoview ceph

Citation: Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent

Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
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SMGr up Copyright  Kulshrestha R

• Storage and retrieval; Manipulation of virtual models

• Diagnostic versatility; Manipulation of virtual models is possible by using the Orthocad
• Transferability; proprietary software and the virtual 3-D images are downloaded from
the main server by the account holder.
• Durability.
Static views from any perspective
The introduction of digital models offers the orthodontist an
alternative to plaster study models routinely used. The digital study Orthocad three-dimensional browsers allow five simultaneous
models overcome most of the drawbacks of plaster study models views of models, thus allowing them to be examined from five
in addition to being the last component of a fully electronic patient different perspectives instead of having to rotate a particular view
chart (with digital photography and digital radiography already in [16,18].
use). This computerized system opens a new realm of orthodontic Grab and drag manipulation in all planes of space
diagnosis (Figure 3).
The jaw alignment tool enables the clinician to fine tune occlusion
Procedure [17]
in case wax bite has distorted. The relationship of jaw can be recorded
There are two basic methods of producing digital study models: anteroposteriorly, between the limits of centric relation and centric
occlusion and software remember this relationship.
Destructive imaging: Removes part of a cast, little at a time, while
it is being imaged. Occlusogram views highlighting occlusal contacts
Non-destructive imaging: uses structured light, laser light, or The computer-generated occlusogram has a colour scheme
x-ray to an image while leaving the original cast intact. that portrays tightness of contact points between jaws, essentially
Two successful companies in producing high-quality 3-D models simulating wax bite width between articulating maxillary and
are: - mandibular teeth. The occlusogram changes if either jaw is moved
laterally or vertically [20]. Occlusal information is important
• Orthocad [16,18] for both initial diagnoses i.e. open versus deep bite, high versus
• Geodigm [17] low mandibular plane angle and for assessment of jaw function.
Furthermore, a comparison of pre and post treatment occlusograms
Orthocad can help evaluate treatment methodology and stability of results.
The Orthocad digital study model capture, assessment, and Transverse and vertical sectioning
storage system are used by approximately 10% of the orthodontists in
USA and Canada [16]. This software has been developed by CADENT Unlike plaster procedures, digital models can be sectioned any
(computer aided dentistry, Fairview, NJ, USA.). They use state of time in the sagittal or transverse plane. This may shed a new light on
the art computer-aided design to optically scan in the model image dental and skeletal asymmetries and can help pinpoint skeletal and
from a plaster equivalent. These are then presented to orthodontist dental midlines.
through the patent orthocad software user interface that allows both Diagnostics
structured and free manipulation of models in virtual space, and data
collection through a range of diagnostic tools. Measurements are made with a virtual caliper and automatically
stored. Various analysis like tooth width measurements, space
Procedure assessment, Moyers and Tanaka-Johnston prediction, Bolton
High-Quality Impressions: It is essential to take high-quality
impressions and a bite registration. The impressions can be taken
in high-quality alginate, polyvinyl silicone or polyether material.
The aim is to produce impressions that are extremely accurate and
dimensionally stable. The alginate impressions are then sanitized
wrapped in lamp paper towel and placed in sealable plastic bags
to ensure retention of moisture. The impressions are then shipped
and in a case of longer periods for shipping and storage polyether
materials may be used.
Scanning of impressions

When the impressions are received, they are converted to plaster

equivalents and optically scanned without destruction of plaster
equivalent into the Orthocad computer system. Then the patient’s
Figure 3: Digital Study Models (Orthocad).
virtual 3-D models are downloaded to your computer [19].

Citation: Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent

Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
Page 4/8
SMGr up Copyright  Kulshrestha R

analysis, arch width measurements can be made. The virtual caliper data storage. Using models, the clinician can move, rotate, or zoom
allows any section of the model to be measured within 100 microns in any plane or orientation. Point to point, Bolton analysis, and curve
(0.1 mm). These are then calculated along with arch form and arch length measurement can easily be made by pointing and clicking
size to give space discrepancy. All contact points and measurements the mouse. Colour bite mapping features permit analysis of occlusal
are saved with Individual patient folder into which the digital model relationships, 3D colour coded map demonstrates occlusal content
is also incorporated for future references. They can also be e-mailed to between arches. In addition, there is an articulation feature which
fellow dentists and other health professionals along with notes, views, allows the clinician to set the centre of rotation. The articulation
and measurements. process can be animated and viewed as occlusal contact happens.
One of latest developments is e-plan, which simulates multiple
Advantages treatment plans to help determine most effective treatment. This
• It is a simpler and more effective way of measuring and storing also allows simulation of rotation movements and allows patient to
data received from a virtual model view their own teeth from malocclusion to a post treatment view. The
opportunities for 3D technology are endless. These new software’s are
• Ease of storage and integration into the patient’s digital file along providing new efficiency for doctors and enhanced patient care.
with digital photographs, X-ray, and clinical notes
Ultrasonography
• Retrieval and viewing along with the patient’s other clinical data
can be done at chair side The phenomenon perceived a sound is the result of periodic
changes in pressure in the air against the eardrum. The periodicity of
• Can be transferred to other healthcare personnel via prints or these changes lies anywhere between 1500 and 20000 cycles per second
e-mail attachment (hertz, Hz). By definition, ultrasound has a periodicity of greater than
Disadvantages 20 kHz. Thus it is distinguished from other mechanical waveforms
simply by having a vibratory frequency greater than audible range.
• Virtual models cannot be mounted and articulated in reference to Diagnostic Ultrasonography, the clinical application of Ultrasound,
patients TMJ functions, although jaw alignment tool comes close employs vibratory frequency in the range of 1 to 20 MHz. [21]
to this Scanners used for sonography generate electrical impulses that are
• The models are expensive and cost about 36$ per set of models considered with high-frequency sound waves by a transducer, which
and shipping costs about 55$ is a device that converts one form of energy to another, in this case,
sonic energy to electrical energy (Figure 4). The most important part
• Time-consuming of the transducer is a thin piezoelectric crystal or material made up of
• The main reason why only 10% of orthodontists use it is that the a great number of dipoles arranged in a geometric pattern. A dipole is
a distorted molecule with a positive charge on one side and negative
legal acceptance of digital study models is still questionable
charge on the other. Currently most widely used piezoelectric material
Orthocad could revolutionize the way in which study models are is Lead Zirconate. The electrical impulse generated by scanner causes
viewed, managed and stored. The ability to rotate, tilt and section dipoles within crystal to realign themselves within electric field and
models, and hold them in any position, allows for detailed analysis, thus suddenly change a series of vibration that produces sound waves
with added advantage of bringing models up instantly with other that are transmitted into tissue being examined [22].
clinical information, chair side. In an era of electronic patient records,
As ultrasound beam passes through or interacts with tissues of
when all patient information is stored digitally, commercially available
different acoustic impedance, it is attenuated by a combination of
digital model systems, such as orthocad will soon be the norm.
absorption, reflection, refraction, and diffusion. Sonic waves that
Geodigm are reflected back (echoes) towards transducer causes a change in
Geodigm E-models are constructed through a proprietary laser
scanning process, that digitally maps the geometry of patient’s
anatomy into a high dimensional 3-D image, with an accuracy of
0.1 mm. Scanners project a laser stripe on the surface of the cast and
use digital cameras to analyze distortions in the stripe. The cast is
oriented in all axes to expose for scanning. This produces 3D vertices
that are connected to thousands of triangles to form the 3D image.
The software then displays the e-model on the computer screen by
giving colour shades, to each triangle based on its orientation to a
digital light source. The result is a 3D image, which can be viewed,
measured or manipulated on screen as if it is cast in your hand [17].
Clinical Management of Models
The orthodontist sends the impressions and bite registration to
Geodigm and plaster cast is made which is scanned to an e model
and articulated. The model can be then downloaded from the main
Figure 4: Ultrasonography Process.
server. A copy is maintained on Geodigm server for the security of

Citation: Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent

Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
Page 5/8
SMGr up Copyright  Kulshrestha R

thickness of the piezoelectric crystal, which in turn produces an observe tongue movements, this causes various artifacts resulting
electric signal that is amplified, processed and then displayed on a in inaccurate measurements of tongue movements. A cushion
monitor. On this system, transducer serves both as receiver and scanning method provides a solution to these problems. With a
transmitter. High-resolution systems may offer a slight thickness cushion scanning system that consists of a cushion device, a head
of 0.5 mm or less and a lateral resolution of 1 mm. Techniques support, a probe holder, and a head position recording device, the
currently in use permit echoes to be processed at a sufficiently rapid tongue dynamic can be correctly recorded and measured. Therefore,
rate to allow perception of motion. This is called real time imaging noninvasive real-time B+M-mode ultrasonography with CST has
[23]. In contrast to x-ray imaging, where an image is produced by become the state-of-the-art tool to study tongue morphology and
transmitted imaging here it is produced by reflectors portion of the observe tongue functions such as swallowing and speech.
beam. The fraction of the beam that is reflected back to the transducer Ultrasound Imaging of Condylar Motion [27]
is dependent on the acoustic impedance of tissue, which is a product
of its density (and thus the velocity of sound through it) and beam Imaging of the temporomandibular joint in an effort to
angle of incidence. Because of its acoustic impedance, a tissue has understand normal and abnormal function continues to be a
an internal echo pattern that is characteristic. The changes in echo challenge. The principal methods currently used to image the joint
pattern are correlated with pathologic changes in tissue, thus not in the sagittal view are x-rays, magnetic resonance imaging, and
knowledge of only technique, but also the anatomy of the structure arthroscopy. The main disadvantage of x-rays is that they provide a
is a must. static view while exposing the surrounding structures to radiation.
With magnetic resonance imaging, the patient’s head position is
Applications (In Head and Neck) [24] abnormal, which can influence mandibular motion. It is a costly
Mainly used in imaging of - procedure and often requires the patient to travel to a special facility.
Arthroscopy involves surgical invasion of the joint with attendant
• Lymph nodes surgical risks as well as the significant likelihood of altering normal
function by its presence. Ultrasound imaging has been recognized for
• Post surgery, edema, and hematoma
some time as having several important advantages: it does not require
• Eye, thyroid gland, and parotid gland special facilities and thus has the potential to become available in an
orthodontic office, and it can be used to view the joint in a continuum
• Submandibular salivary gland
without invasion, discomfort, alteration of the patient’s normal head
• To demonstrate thickness of masticatory mucosa posture, or interference with condylar motion.

• Demonstrate displacement of soft tissue under denture by forces Audio frequencies greater than 1600 Hz (cycles per second) are
of occlusion considered ultrasonic. An ultrasonic sound wave passing through the
tissue will have a portion of the sound wave reflected on transiting
Comparison of Tongue Functions between Mature dissimilar tissues. This reflected energy is returned to the ultrasonic
and Tongue-Thrust Swallowing [25] emitting device (transducer) where the location of the interface is
Tongue functions during swallowing are of interest to many determined, and an appropriate image is produced representing
orthodontists. In normal deglutition, the tip of the tongue rests on the the interface contours. In earlier studies, ultrasonic transducers
lingual part of the dentoalveolar area, the contraction of the perioral have been placed at various parts of the skin surfaces related to the
muscles is minimal during deglutition, the teeth are in momentary temporomandibular joint area. This produced nonconventional
contact during swallowing, and there is neither a tongue thrust nor a images of the joint from the frontal, superior, or both aspects. Recently
constant forward posture. Several methods for evaluation of tongue Hirt and Knupfer obtained images of the temporomandibular joint in
movements, such as radio-cinematography, electromyography, the more conventional sagittal plane. These were images of the joints
of cadavers. Until now, obtaining conventional (sagittal) images of
and electromagnetic articulography, have been used in previous
the temporomandibular joint via sonography has been limited for
studies. Electropalatography and electromagnetic articulography
several reasons. Ultrasound is unable to penetrate the relatively large
are not suitable for examining normal tongue function because it
mass of bone overlying the joint, and the size of the transducer has
is difficult for subjects to swallow normally with receiver coils and
prevented its strategic placement in order to produce conventional
wires attached to their palates or tongues. X-ray cinematography
sagittal images [27].
and computerized tomography have the disadvantage of radiation
exposure. Magnetic resonance imaging is not suitable for examining Three-dimensional ultrasonography
swallowing movements because of its high cost and long acquisition
time [26]. Ultrasonography has the advantages of being non-invasive, Three-dimensional ultrasound imaging is a new technology
rapid, easily repeatable, and relatively inexpensive. Ultrasonography that presents views of the fetal face with greater clarity than the
has been used in many studies for static imaging of the oral cavity (e.g. conventional two-dimensional imaging described previously. The
for studying tongue morphology and for diagnosis of sialolithiasis, advantages include viewing of the face in a standard anatomic
cysts, and tumours). Dynamic ultrasound investigation of tongue orientation, manipulation of planar views without concern for fetal
movement, identification of the exact location of the planar images
movement through sub mental scanning has been described by many
relative to the surface facial image, and easy interpretation of the
researchers.
lifelike rendered three-dimensional images by a non-trained observer.
A major obstacle of these previous dynamic ultrasound studies The sensitivity of three-dimensional imaging in diagnosing cleft lip
was that they used direct transducer-skin coupling scanning to and palate is considerably greater than two-dimensional imaging.

Citation: Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent

Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
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SMGr up Copyright  Kulshrestha R

Sure Smile Once the process is complete the teeth can be moved like independent
objects in 3 dimensions with software controls. The windows based
Recent advances in computer management 3D imaging of software allows the operator to diagnose plan treatment and simulate
dentition, manipulation of complex 3D data, and robotics have the results. 3D viewing of models like frontal, lateral, posterior
resulted in a new approach to treatment [28]. A patient centred or occlusal views or different perceptive by using navigation tools.
practice is one that delivers high-quality care with a minimum
The teeth can also be viewed in individual arches. The operator can
amount of patient discomfort, compliance demand and chair time
diagnose and plan the treatment with tools to measure tooth and arch
and completes treatment on time.
dimensions and symmetric and asymmetric arch forms. A coronal
Benefits of Sure Smile cross section like a 3D CAT scan is also available for evaluation of 3rd
order relationship.
• Reduce errors in treatment resulting from appliance management
The clinician plans treatment on parameters such as midline,
• It provides image capturing, 3D visualization of tools for occlusal plane and arch dimensions, multiple plans are to be simulated
diagnosis, monitoring, and patient communication along with for comparison. The final treatment plan is then represented in form
precision appliances that can help the orthodontist to deliver
of 3D diagnostic setup – the Target occlusion. The operator can get
truly customized care in a patient oriented practice.
treatment alternative by moving the teeth with a mouse or selected
Clinical Procedures [29] menus by enhancing or reducing teeth mesially or distally to simulate
inter-proximal disking. The changed in X, Y and Z coordinates can be
The process begins with a 3D scan of patients dentition using done in individual teeth to show case difficulty and treatment changes.
the oro-scanner (oro matrix) a hand held scanner, this captures in Inter-arch contact and relations, such as overbite and overjet can be
real time in vivo images of dentition. The dentition is prepared for viewed with a cutting plane tool, which displays an inter-proximal or
scanning by applying a thin white film, similar to articulating spot a transverse view at any location along with the arch. Once the target
spray. It uses structured white light to generate images in rapid
occlusion is done the digital bonding system form library is selected.
succession by projecting a precisely patterned grid on to the teeth. As
Then geometric calculation and incorporation of various forces into
the hand held scanner is passed over the dentition, reflected images
the wires and their impact in teeth can be calculated. The operator
of dentition, reflected images of a distorted grid are recorded with
based on the amount of tooth movement and forces required can
a video camera built into the handle of the scanner. The scanner is
decide the optimal treatment plan. Any errors in positioning brackets
passed over the dentition in a rocking motion to allow visualization of
and wire combination can be managed at any stage during the cycle.
all tooth surfaces, including undercut areas. The entire process takes
New oral scans can be used for designing finished wires and fixed 3-3
about 1½ minutes per arch. The image is reference independent;
lingual retainers before deboning.
meaning the image capturing process is not affected by the movement
of patient or scanner. The scanner is placed in a mobile care smile cart Advantages of Sure Smile [29]
that rolls from chair to chair. During the scanning stage, the multiple
• Undesirable tooth movement may be reduced
and over lapping images go to the computer. With sophisticated data
registration and management techniques, the images are processed • Arch-wire selection errors may be reduced
and the computer model is created. The teeth are then compared
with teeth in a library of dental morphology. Information voids in • Bracket positioning errors may be reduced
the scan are filled with data from the library to further refine models • Bonding adhesive thickness errors can be reduced
(Figure 5).
Accuracy of System [30]
A full oral scan is taken and integrated with conventional
photographs and x-rays and entered into the electronic patient chart. • Oro scanner – unblurred images per second with as many as 3500
3D measuring points per image
• Greater accuracy of each points more than 50 microns, a linear
error of 0.1 mm per tooth
• Wire bending – Bend positioning error ± 0.1mm, Angular/
torsional error ± 10
• Digital bracket movement ± 25microns; in vivo ± 1mm
Conclusion
The above mentioned technological advancements have helped
not only the Orthodontists but the whole dental community. These
advancements can be used in all branches of dentistry (Prosthodontics,
Endodontic, Oral surgery etc). Diagnosis and treatment planning
has become much more accurate, easier and less time consuming
with these software’s. Researchers and developers are striving hard
continuously to make dentistry easier for all practitioners worldwide.
Figure 5: Sure Smile Technology.
Their dedication and efforts are very well appreciated and hope

Citation: Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent

Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
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SMGr up Copyright  Kulshrestha R

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Citation: Kakadiya A, Tandon R, Azam A, Kulshrestha R and Bhardwaj M. Recent

Advancements in Diagnostic Aids in Orthodontics - A Review. SM J Dent. 2017; 3(2): 1016.
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