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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 180-186

Three methods comparison using two-dimensional software (a novel technique), tri-dimensional cone-beam computed tomography, and manual method to measure maxillary casts: Unilateral and bilateral cleft lip and palate infants up to 6 months


1 Department of Orthodontics, Yenepoya Dental College, Deralakatte, Mangalore, Karnataka, India
2 Department of Orthodontics, Malla Reddy Institute of Dental Sciences, Hyderabad, Andhra Pradesh, India
3 Department of Periodontics, Malla Reddy Institute of Dental Sciences, Hyderabad, Andhra Pradesh, India
4 Department of Oral Medicine and Radiology, Malla Reddy Institute of Dental Sciences, Hyderabad, Andhra Pradesh, India

Date of Web Publication21-Nov-2017

Correspondence Address:
Mohammadi Begum Khan
Department of Orthodontics, Yenepoya Dental College, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_60_17

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  Abstract 

Objective: The objective of the study was to investigate any relationship between three different methods of measurements used to measure certain parameters used on the casts of infants born with cleft lip and palate (CLP). Materials and Methods: A set of 25 casts including both unilateral and bilateral CLP were used to determine the relationship among three different methods used in this study, including tri-dimensional (3D) cone-beam computed tomography, two-dimensional (2D) software, and manual method using Vernier caliper. Results: Linear regression analysis or regression curves were attempted to establish a relationship among three different methods. Statistically significant difference (P < 5%) was found for almost all the measurements analyzed. The measurements obtained by Vernier caliper were found to be close to software values than 3D values. The ability of obtaining a 3D value from a measured 2D value was determined as the linear Pearson's correlation coefficient R and the amount of scatter around the regression line as represented by 95% confidence interval. Total error of 3D value calculated from 2D measurements was obtained by regression analysis. Conclusion: Through this study, it was concluded that newer and simpler methods for measurement purpose are always accepted on a wider scale and can be employed universally. We could find that 2D measurements by Vernier caliper which is closer to software measurements (using MAKHTER Software) can be converted to 3D using a multiplication factor of 0.54.

Keywords: Cleft lip and palate, digitization, plaster casts, tri-dimensional cone-beam computed tomography, two-dimensional software, Vernier caliper


How to cite this article:
Khan FA, Khan MB, Hussain A, Karra A, Usha P, Lalitha C H. Three methods comparison using two-dimensional software (a novel technique), tri-dimensional cone-beam computed tomography, and manual method to measure maxillary casts: Unilateral and bilateral cleft lip and palate infants up to 6 months. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:180-6

How to cite this URL:
Khan FA, Khan MB, Hussain A, Karra A, Usha P, Lalitha C H. Three methods comparison using two-dimensional software (a novel technique), tri-dimensional cone-beam computed tomography, and manual method to measure maxillary casts: Unilateral and bilateral cleft lip and palate infants up to 6 months. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:180-6. Available from: https://www.jclpca.org/text.asp?2017/4/3/180/218879


  Introduction Top


Clefts of the lip and palate are the most common craniofacial anomalies listed out in the world, which start affecting the developing embryo in the 4th–8th week of intrauterine life, which basically involves the stage development of face and the palate. Cleft lip and palate (CLP) represents a major burden for health sector for its complex etiology and various combinations of presentation as well as varying treatment approaches adopted for its treatment by multidisciplinary team specialists. The management part of this anomaly involves a multidisciplinary approach which basically includes plastic surgeons, oral surgeon, otolaryngologist, speech therapist, and orthodontists. The optimum treatment plan includes primary surgery to close the defect and orthodontic plan alongside speech therapy followed by secondary and tertiary surgeries to refine the initial surgical results. Since the primary surgical procedures are planned within the first 6 months after birth, the neonates are subjected to various surgeries including surgical closure of the cleft lip segments and/or alongside the closure of the palatal defects, for which the documentation of the anatomical measurements of the areas involved plays a critical role to determine the success of the intervention used for the unique type of cleft presentations so that the particular approach is accepted widely and longitudinally and adopted universally for its acceptable and standardized therapeutic benefits.

Significance of the study

The use of landmarks and tri-dimensional (3D) images for the study of dental casts has been a method largely employed for serving the purpose of studying the maxillary growth and development, to acknowledge and recognize the effects of the repair surgeries and to study the maxillary morphology alterations in CLP patients. Although the measurements carried out on the surface of the maxillary plaster casts, for example, linear distances, 3D curve lengths, 3D surface areas are seen to be replacing the two-dimensional (2D) methods of measurements, for example, photographs and manual methods. However, widespread use of new 3D technologies is still lagging due to several disadvantages such as high cost of scanning hardware, cumbersome use, lack of efficient software standardization, and ease of calibration. Therefore, with this study, we tried attempting to compare the values obtained using these three different methods (2D-software, 3D cone-beam computed tomography [CBCT], and manual method using Vernier caliper) and tried establishing a relationship among these three methods, thereby overcoming the shortcomings of any single method used.

Aims and objectives

The aim and objective of the study were to investigate the relationship between corresponding 2D, 3D, and manual methods for measurements of a set of variables on the plaster casts of the neonates born with cleft of the lip and palate (both unilateral and bilateral CLP [UCLP and BCLP]) using a novel software (MAKHTER software) under 2D method and comparing the parameters with those obtained using 3D CBCT and further comparing these two methods with another manual method using Vernier caliper for the same set of predetermined variables to determine any significant relationship existing among these three different methods of measurements.


  Materials and Methods Top


A set of 25 casts of unilateral and bilateral cleft palate cases have been selected from a sample of infants reported to Yenepoya Center of Craniofacial Anomalies in the age range of 10 weeks–6 months. Corresponding 2D and 3D and manual measurements of the cleft width, major and minor segment arch lengths (MS-L and MIN S-L), and intercanine and intermolar distances were carried out, and the relationship between 2D and 3D and manual methods of measurements was investigated using linear regression analysis.

Inclusion criteria

  • Age range from 6 weeks to 6 months
  • Infants without any associated syndromes and systemic debilitated diseases
  • All preoperated cases where only nasoalveolar molding (NAM) was performed
  • All treated for NAM by the same orthodontist at the same clinical setup (Yenepoya University).


Exclusion criteria

  • Incomplete cleft of the lip and palate
  • Infants with associated systemic diseases and syndromes
  • Malnourished infants
  • Dissatisfactory cooperation for NAM by the parents group.


Methodology

A set of 15 UCLP and 10 BCLP was selected and subjected to the measurements using MAKHTER software (MAKHTER software: Developed by Dr. Akhter Hussain and Dr. Makheeja, used for the 2D analysis of the images in linear and curved planes) for 2D analysis and CBCT for 3D analysis of the data and stored as such two examiners repeating the measurements after a period of 1 week. After obtaining the measurements, a relationship between the corresponding 2D and 3D measurements as well as total error of obtaining 3D from 2D measurements was established, and also the manual measurements using Vernier caliper were compared with these two methods for determining any significant relationship among these three methods of measurements. The inter- and intra-examiner agreement and correlation were assessed using weighted Kappa and Spearman's correlation coefficient. The agreement was found to be moderate with a Kappa value of 0.52, and correlation was found to be statistically significant with (P < 0.01) with a coefficient value of 0.80.

Brief description about the MAKHTER software used for two-dimensional measurements

This software though was developed to overcome the challenge for manual analysis of facial parameters because of its difficulty in usage, time-consuming characteristics, and a lot of manual intervention. Hence, there was felt an intense need for a software which can make the measurement task easier. Keeping this in mind, a “FACIAL ANALYSIS SOFTWARE” was developed. Although it was developed to be used for measuring the soft-tissue facial parameters on the photographs and videographs that are uploaded in this software, through this study, we attempted to use the same software to determine the specific parameters on the photographs of the casts of the infant cleft babies. The photographs were standardized and digitized for the particular landmarks, for which the definitions would be fed in the system which utilizes this information to give the precise measurements on clicking the icon bar [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Two-dimensional software (MAKHTER) shown on the home screen

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Figure 2: Plaster casts are standardized using a metallic scale in millimeters

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Figure 3 (a-e): Plaster casts being subjected to tri-dimensional cone-beam computed tomography and Vernier caliper measurements

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Figure 4 (a,b): Plaster casts being subjected to two-dimensional software measurements

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Measurements and definitions

  1. Anterior cleft width (CW)
  2. Palatal segment arch length (MS-L and MIN S-L)
  3. Intercanine width
  4. Intermolar width
  5. Palatal surface area and ratio of the cleft area to the total palatal surface area.


Statistical analysis

Linear regression analysis or regression curves was attempted to establish a relationship among three different methods. In an attempt to estimate 3D quantities from 2D measurements, it is important to keep in mind that the calibration curves (regression curves) have been obtained for a particular set of conditions. Calibration curves should be created for each population under study (e.g., different curves for UCLP and BCLP and for different age ranges). Furthermore, separate calibration curves should be created for each quantity to be measured (e.g., alveolar arch length and palatal segment area), and the definition of these quantities must not differ between calibration and measurement. The mountain plot provides information about the distribution of the differences in the measurement methods used in this study [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Figure 5: (a-d) Mountain plot drawn for three different methods comparison for measurement of cleft width

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Figure 6 (a-d): Mountain plot drawn for three diffetent methods for comparison of arch length

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Figure 7 (a-d): Mountain plot drawn for comparing three different methods for intercanine and intermolar width

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Figure 8 (a,b): Regression or calibration curves obtained for different parameters

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  1. Total error of obtaining 3D value estimated from 2D measurements: The ability of obtaining a 3D value from a measured 2D value was determined as the linear Pearson correlation coefficient R and the amount of scatter around the regression line as represented by 95% confidence interval. Total error of 3D value calculated from 2D measurements was obtained by regression analysis
  2. Error in calculating 3D values from 2D measurements: It includes errors due to 2D measurements, due to plaster cast orientation, and due to shape variability. 2D measurement error: Due to image distortion or limited resolution of the capturing device.



  Results Top


The results indicated that there could be subtle range of error difference of reliability, reproducibility (intraobserver concordance), and precision (standard deviation and standard error) between the two methods (3D CBCT and MAKHTER software) used to perform the digital measurements of the various parameters. Although the manual method was found to be closer to the 2D software, measurements values for many variables were assessed. Statistically significant difference (P < 5%) was found for almost all the measurements analyzed. The measurements obtained by Vernier caliper were found to be close to software values than 3D values. Keeping the limitations in mind, it can be concluded that the 2D measurements by Vernier which were found closer to software measurements (using MAKHTER Software) can be converted to 3D values using a multiplication factor of 0.54.

  1. 2D versus 3D measurements: The regression line is given by P3D = 1.10 × P2D + 83.6
  2. 3D measurement error: Inter- and intra-observer error were found to be 2.3% and 3%
  3. 2D measurement error due to distortion of photograph was found to be 1.3% with inter- and intra-observer variability of 2.1%
  4. Errors in calculating 3D values from 2D measurements: Error due to variability of plaster cast orientation was found to be 0.7%, error due to natural shape variability of the palatal cast was found to be 3.7%, and error of cleft palate ratio was found to be 7%.



  Discussion Top


Through this study, an attempt is made to use a 2D or 3D method which could be affordable in terms of finances and of course be less time-consuming, accurate in its measurement values, and easier in its application methodology. This study tried comparing three different methods, wherein a group of 25 casts of both UCLP and BCLP were taken from an age range from 3 weeks to 6 months and subjected to analysis for various parameters selected beforehand. The various methods used in this study include 3D CBCT and 2D software using photographs of the casts and manual measurement using Vernier caliper. The results were found to be showing significant variations among each other for most of the variables although there were minimal errors noted between manual and 2D software showing that the values were close to each other. We summarize to say that the reliability and accuracy of measurements play an important role for the measurements on the casts of CLP infants which again would be of immense help in determining the success of various interventions used in these individuals as numerous techniques have been employed worldwide for their rehabilitation. Our study thus can be supported by various other studies done in the past which tried to document the reliability and importance of the measurements done on the casts of the CLP individuals. It was Seckel et al.[1] in 1995 who affirmed that the reproducible landmark positioning can only be a reality if the quality of the cast is optimal, and the investigator is experienced and even then only for some of the landmarks investigated. Reproducibility might be enhanced by additional information from serial casts of the same individual. Foong et al.[2] in 1999 determined the reliability of the surface laser-scanning technique and assessed the reliability of interactive 3D landmark localization. Original and duplicate plaster casts of an infant with a complete UCLP were digitized with a laser scanner. The authors concluded that landmarks well defined by a clearly visible visual cue on the 3D image were more reliable. Prahl et al. in 2001[3] stated that the CLP infants, the quantitative analysis of the palatal morphology before, during, and at the end of the treatment revealed better appreciation of the actual effect of the various protocols employed for their rehabilitation including surgical interventions. Oostercamp et al. in 2006[4] and Wutzl et al. in 2009[5] emphasized that the studies starting at birth are necessary to evaluate the treatment protocol and that dental casts serve an important tool for documenting the original maxilla tooth status. Many studies used maxillary arch dimensions and landmarks for analysis of the development and growth in patients with CLP. Asquith et al in 2012[6] said that the needs of patients with a cleft lip and/or palate (CL/P) extend beyond surgical repair, and therefore, multidisciplinary approach to the care of patients with CLP is the widely accepted standard of care in most regions of the developed world. Asquith and McIntyre[6] in 2012 tried explaining if the 3D study models could replace the plaster casts to avoid time and storage space, thus supporting the use of digitized casts which could be experimented with various types of softwares to assess the measurements of the parameters chosen, especially in CLP newborns. The methodology used by Mello et al.[7] in 2013 used a 3D imaging method to measure 3–9-month-old unoperated patients with different types of cleft. Their data showed that BCLP and UCLP had significantly larger intercanine distance than control group. Other studies confirmed the difference between patients with and without cleft emphasizing the significance of measurement accuracy and reliability of different landmarks in CLP cases. The methodology used by Falzoni et al.[8] in 2016 revealed a method to obtain measurements through 3D images of CLP children at two treatment periods: previous to cheiloplasty and 1 year after palatoplasty. The results of their study showed that the lip surgery had a restrictive shaping effect on the anterior portion of the dental arch of UCLP children, thus supporting the significance of the measurement tasks in this area of research. Similarly, Lambert et al.[9] in 2016 found out that differences in the CW between the groups with isolated cleft palate and with cleft of the lip and palate, thus supporting the work where the measurement accuracy could be attempted so that the best and innovative yet simple technique can be utilized for a larger population range.


  Conclusion Top


Over a period, various methods have been tried to be employed in measuring various landmarks and parameters on the casts of CLP infants. These methods have been serving as standard source of documentation to determine the efficacy of various interventions used to treat this commonly seen craniofacial anomaly, i.e. cleft lip and palate. Through this study, we have tried using our own innovated 2D software technique which was developed with the intention to be used in various facial soft-tissue analysis using photographs of the individuals. Here, we tried using this technique for measurements to be made on the photographs of the casts of the CLP infants. We also tried comparing the values with routinely used 3D CBCT and manual method using Vernier caliper to determine any relationship among these three methods statistically significant. We conclude our study with the revelation that our manual values were found closer to 2D method, and there was found a relationship between 2D measurements 3D values using a multiplication factor of 0.54.

Acknowledgment

The work is dedicated to Yenepoya University and all the authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Seckel NG, van der Tweel I, Elema GA, Specken TF. Landmark positioning on maxilla of cleft lip and palate infant – A reality? Cleft Palate Craniofac J 1995;32:434-41.  Back to cited text no. 1
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2.
Foong KW, Sandham A, Ong SH, Wong CW, Wang Y, Kassim A, et al. Surface laser scanning of the cleft palate deformity – Validation of the method. Ann Acad Med Singapore 1999;28:642-9.  Back to cited text no. 2
    
3.
Prahl C, Kuijpers-Jagtman AM, van't Hof MA, Prahl-Andersen B. A randomised prospective clinical trial into the effect of infant orthopaedics on maxillary arch dimensions in unilateral cleft lip and palate (Dutchcleft). Eur J Oral Sci 2001;109:297-305.  Back to cited text no. 3
    
4.
Oosterkamp BC, van der Meer WJ, Rutenfrans M, Dijkstra PU. Reliability of linear measurements on a virtual bilateral cleft lip and palate model. Cleft Palate Craniofac J 2006;43:519-23.  Back to cited text no. 4
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5.
Wutzl A, Sinko K, Shengelia N, Brozek W, Watzinger F, Schicho K, et al. Examination of dental casts in newborns with bilateral complete cleft lip and palate. Int J Oral Maxillofac Surg 2009;38:1025-9.  Back to cited text no. 5
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6.
Asquith JA, McIntyre GT. Dental arch relationships on three-dimensional digital study models and conventional plaster study models for patients with unilateral cleft lip and palate. Cleft Palate Craniofac J 2012;49:530-4.  Back to cited text no. 6
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7.
Mello BZ, Fernandes VM, Carrara CF, Machado MA, Garib DG, Oliveira TM, et al. Evaluation of the intercanine distance in newborns with cleft lip and palate using 3D digital casts. J Appl Oral Sci 2013;21:437-42.  Back to cited text no. 7
    
8.
Falzoni MM, Jorge PK, Laskos KV, Carrara CF, Machado MA, Valarelli FP, et al. Three-dimensional dental arch evaluation of children with unilateral complete cleft lip and palate. Dent Oral Craniofac Res 2016;2:238-41.  Back to cited text no. 8
    
9.
Lambert A, Piché M, Leclerc JE. Detailed cleft measurements: A comparison between isolated cleft palates and cleft palates associated with cleft lips. Cleft Palate Craniofac J 2016;53:309-16.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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