title: Precision of manual landmark identification between as-received and oriented volume-rendered cone-beam computed tomography images.
abstract: BACKGROUND
  The objective of this study was to evaluate the effect of the orientation of cone-beam computed tomography (CBCT) images on the precision and reliability of 3-dimensional cephalometric landmark identification.
  
  
  METHODS
  Ten CBCT scans were used for manual landmark identification. Volume-rendered images were oriented by aligning the Frankfort horizontal and transorbital planes horizontally, and the midsagittal plane vertically. A total of 20 CBCT images (10 as-received and 10 oriented) were anonymized, and 3 random sets were generated for manual landmark plotting by 3 expert orthodontists. Twenty-five landmarks were identified for plotting on each anonymized image independently. Hence, a total of 60 images were marked by the orthodontists. After landmark plotting, the randomized samples were decoded and regrouped into as-received and oriented data sets for analysis and comparison. Means and standard deviations of the x-, y-, and z-axis coordinates were calculated for each landmark to measure the central tendency. Intraclass correlation coefficients were calculated to analyze the interobserver reliability of landmark plotting in the 3 axes in both situations. Paired t tests were applied on the mean Euclidean distance computed separately for each landmark to evaluate the effect of 3-dimensional image orientation.
  
  
  RESULTS
  Interobserver reliability (intraclass correlation coefficient, >0.9) was excellent for all 25 landmarks for the x-, y-, and z-axes on both before and after orientation of the images. Paired t test results showed insignificant differences for the orientation of volume-rendered images for all landmarks except 3: R1 left (P = 0.0138), sella (P = 0.0490), and frontozygomatic left (P = 0.0493). Also midline structures such as Bolton and nasion were plotted more consistently or precisely than bilateral structures.
  
  
  CONCLUSIONS
  Orientation of the CBCT image does not enhance the precision of landmark plotting if each landmark is defined properly on multiplanar reconstruction slices and rendered images, and the clinician has sufficient training. The consistency of landmark identification is influenced by their anatomic locations on the midline, bilateral, and curved structures.
authors.affiliation: Academy of Scientific and Innovative Research (AcSIR), CSIR-Central Scientific Instruments Organisation (CSIO) Campus, Chandigarh, India.
authors.forename: Abhishek
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Centre for Dental Education and Research; Division of Orthodontics and Dentofacial Deformities, All India Institute of Medical Sciences, New Delhi, India. Electronic address: opk15@hotmail.com.
authors.forename: Om Prakash
authors.initials: OP
authors.lastname: Kharbanda
authors.affiliation: Division of Orthodontics and Dentofacial Deformities, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Balachandran
authors.affiliation: CSIR-Central Scientific Instruments Organisation, Chandigarh, India.
authors.forename: Viren
authors.initials: V
authors.lastname: Sardana
authors.affiliation: Division of Orthodontics and Dentofacial Deformities, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Shilpa
authors.initials: S
authors.lastname: Kalra
authors.affiliation: Division of Orthodontics and Dentofacial Deformities, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Sushma
authors.initials: S
authors.lastname: Chaurasia
authors.affiliation: CSIR-Central Scientific Instruments Organisation (CSIO); Academy of Scientific and Innovative Research (AcSIR-CSIO), Chandigarh, India.
authors.forename: Harish Kumar
authors.initials: HK
authors.lastname: Sardana
mesh_terms: D059925:Anatomic Landmarks; D002508:Cephalometry / Q000379:methods*; D054893:Cone-Beam Computed Tomography / Q000379:methods*; D006801:Humans; D021621:Imaging, Three-Dimensional; D015588:Observer Variation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity