Originl Article Influence of lterl cephlometric rdiogrphy in orthodontic dignosis nd tretment plnning An Reis Durão ; Ali Alqerbn b ; Afonso Pinhão Ferreir c ; Reinhilde Jcobs d ABSTRACT Objective: To evlute the impct of dditionl lterl cephlometric rdiogrphy in orthodontic dignosis nd tretment plnning. Mterils nd Methods: Forty-three ptients seeking orthodontic tretment, nd for whom pretretment dignostic records were vilble, were rndomly selected. Ten qulified orthodontists were involved in this study. The ptients records included three photogrphs of the ngle trimmed dentl csts, digitl lterl cephlometric nd pnormic rdiogrphs, nd stndrd clinicl photogrphs comprising seven intr- nd four extrorl pictures. Records were evluted in two sessions. At the first session, orthodontists evluted records without lterl cephlometric rdiogrphy (LCR). In the second session, the sme informtion ws presented, but with LCR. Between the two sessions the order in which the cses were presented ws ltered to void bis. Results: The percentge of greement between sessions ws lower for dignosis thn for tretment plnning. Concerning skeletl clssifiction, the lest experienced orthodontist ws the lest consistent (28%), while the more experienced orthodontist ws the more relible (67%). In terms of tretment modlities, in generl there ws n greement of 64%. The most frequent modifictions in tretment modlities were seen in Clss II mlocclusion ptients. Conclusions: The results of our study suggest tht the mjority of Portuguese orthodontists judge tht LCR is importnt to producing tretment pln. Despite tht, it does not seem to hve n influence on orthodontic tretment plnning. (Angle Orthod. 2015;85:206 210.) KEY WORDS: Cephlometry; Orthodontics; Tretment; Dignosis INTRODUCTION Since the introduction of lterl cephlometric rdiogrphy (LCR) by Brodbent in 1931, it hs been widely used in orthodontic ssessment nd tretment plnning. 1 3 Despite tht, its usefulness in orthodontics Invited Assistnt, Deprtment of Dentl Rdiology, Fculty of Dentl Medicine, University of Porto, Portugl. b Doctorndus, Deprtment of Orl Helth Sciences, Fculty of Medicine, University Hospitls Leuven, Leuven, Belgium. c Full Professor, Deprtment of Orthodontics, Fculty of Dentl Medicine, University of Porto, Portugl. d Full Professor, OIC, OMFS IMPATH reserch group, Deprtment of Imging & Pthology, Fculty of Medicine, Orl & Mxillofcil Surgery, University Hospitls Leuven, Leuven, Belgium. Corresponding uthor: Dr An Reis Durão, Fculdde de Medicin Dentári d Universidde do Porto, Ru Dr. Mnuel Pereir d Silv, 4200-393 Porto, Portugl (e-mil: pul.o.reis@gmil.com) Accepted: April 2014. Submitted: Jnury 2014. Published Online: My 21, 2014 G 2015 by The EH Angle Eduction nd Reserch Foundtion, Inc. remins questionble. Silling et l. 4 stressed tht LCR ws only needed for Clss II division 1 ptients. Lter, Hn et l. 5 stted tht ptient exmintion together with dentl csts provided sufficient informtion with which to render dignosis. According to them, only 55% of tretment plns were chnged fter LCR evlution. In the sme vein, Bruks et l. 6 suggested tht in 93% of the cses tretment plns remined unchnged fter LCR evlution. They evluted the ptient, dentl csts, nd extrorl photogrphs. In contrst Pe et l. 7 reveled tht in ptients with Clss II division 2 occlusion nd bimxillry protrusion, this rdiogrphy could chnge the decision with regrd to teeth extrction. In 2008, Nijkmp et l. 8 reinforced tht LCR does not seem to hve ny impct on orthodontic tretment plnning for Clss II division 1 ptients. Recently, in 2011 Devereux et l. 9 concluded tht only in one out of six ptients orthodontists decided to chnge their tretment decisions with regrd to tooth extrction. In contrst with the previous study, they suggested tht LCR my be justified for orthodontic tretment. Considering the controversy in the literture, 206 DOI: 10.2319/011214-41.1
LATERAL CEPHALOMETRIC RADIOGRAPHY IN ORTHODONTICS 207 Figure 3. Pnormic rdiogrphs. Figure 1. Dentl cst photogrphs. the present im ws to further explore the impct of dditionl LCR in orthodontic dignosis nd tretment plnning. MATERIALS AND METHODS Forty-three ptients with pretretment dignostic records were rndomly selected. All ptients were seeking orthodontic tretment t the Fculty of Dentl Medicine of the University of Porto. The study ws pproved by the Ethics Committee of the Fculty of Dentl Medicine of University of Porto (900079). The Ptients ges rnged from 10 to 42 yers (24 femle nd 19 mle). Orthodontic dignostic records included three photogrphs of the ngle trimmed dentl csts (Figure 1) nd digitl lterl cephlometric (Figure 2) nd pnormic rdiogrphs (Figure 3), s well s stndrd clinicl photogrphs comprising seven intr- (Figure 4) nd four extrorl pictures (Figure 5). The ptient s identifiction ws blurred to void recognition. All blinded informtion ws sved in pdf file nd recorded on compct disk nd given to ech observer. Ten qulified orthodontists were involved in this study. Their experience rnged from 5 to 24 yers. Ptient records were evluted during two sessions. The time intervl between observtions ws t lest 8 weeks. At the first session orthodontists evluted records without LCR. In the second session the sme informtion ws presented, but this time LCR ws dded. Between the two sessions the order in which the cses were presented ws ltered to void bis. The evlution process for the two sessions involved the use of questionnire concerning dignosis nd tretment plnning; the questionnire contined the following elements/questions: 1. Skeletl reltionship: neutro, disto, or mesio-reltion? 2. Angle clssifiction of occlusion bsed on molr reltionship: on Clss I, Clss II, Clss? Figure 2. Digitl lterl cephlometric rdiogrphy. Figure 4. Introrl photogrphs.
208 DURÃO, ALQERBAN, FERREIRA, JACOBS Tble 1. Men Percentge of Agreement Between the First nd Second Sessions for ll Observers Questions % of Agreement 1 43 2 Right 47 2 Left 50 3 87 4 64 5 58 6 56 7 58 8 Mxill 58 8 Mndible 67 9 65 11 63 Figure 5. Extrorl pictures. 3. Detection of bnormlity? 4. The nture of the tretment will be s follows: orthopedic growth modifiction; orthognthic surgery; or dentolveolr compenstion? 5. Is there enough spce for ll teeth to erupt? 6. Would you extrct teeth in this ptient? If yes, which? 7. Would you expnd the upper rch? 8. Would you use nchorge in the mxill or mndible or both? 9. Do you expect ny complictions during the tretment? 10. How long do you expect tht the tretment will tke? 11. Would you need dditionl informtion to mke decision? Which? nd 12. How long hs it been since you qulified s n orthodontist? Sttisticl Anlysis The percentge of greement of the nswers between the two sessions (rtio of greement between cses nd the totl cses used) ws evluted. This ws crried out for ech ptient to test for differences in the percentges of chnged decisions for dignosis nd tretment plnning. RESULTS The percentge of greement between sessions ws lower with regrd to dignosis thn it ws with regrd to tretment plnning (Tble 1). Tretment plnning seemed to be chnged, on verge, in 36% of the cses by dding LCR. In ddition, the skeletl clssifiction dignosis ws chnged, on verge, in 56% of the cses, nd, in generl, in 52% of the cses the mlocclusion clssifiction seemed to be ltered. The most frequent chnges ppered in Clss II mlocclusion ptients. With regrd to skeletl clssifiction, the lest experienced observer ws the lest consistent (28%), while the more experienced observer ws the more relible (67%). On verge, 10 cses were clssified in the first session s Clss II, nd fter evluting the LCR the dignosis of the skeletl clssifiction chnged to Clss I. In nine cses skeletl clssifiction ws ltered from Clss I to Clss II. Overll, only in single cse did the orthodontists chnge from Clss III to Clss I. The presence of bnormlity reveled very good greement between the two sessions (87% overll). With regrd to tretment modlities, in generl there ws n greement of 64%. The most experienced observer reveled 80% greement between sessions, chnging the tretment pln in only eight cses, while the lower percentge ws of 37%, seen in n observer with 10 yers of prctice. In 26 cses the tretment modlity ws chnged in the mjority of cses, being ltered from dentolveolr compenstion to surgery. The most frequent modifictions in tretment modlities were seen in Clss II ptients. One observer chnged the decision to extrct in 19% of the cses fter evluting the LCR. Tble 2 demonstrtes the comprisons with regrd to tretment durtion, in months, between the first nd second sessions. Only two observers reveled sttisticlly significnt differences. After viewing the LCR, one observer suggested tht the tretment should be longer. On the second
LATERAL CEPHALOMETRIC RADIOGRAPHY IN ORTHODONTICS 209 Tble 2. The Men Differences in Proposed Tretment Pln Durtion (Months) Between the Two Sessions Men, mo SD P* Observer 1.297 First session 28.23 15.057 Second session 30.39 13.647 Observer 2.077 First session 24.42 3.794 Second session 25.57 3.262 Observer 3.366 First session 22.59 2.976 Second session 23.30 1.946 Observer 4.142 First session 27.07 6.724 Second session 25.26 5.164 Observer 5.328 First session 26.38 5.323 Second session 25.58 6.103 Observer 6.979 First session 20.93 4.614 Second session 21.00 4.824 Observer 7.234 First session 30.28 9.881 Second session 31.26 4.640 Observer 8.033* First session 25.26 3.600 Second session 32.09 15.868 Observer 9.726 First session 28.47 5.934 Second session 28.09 7.091 Observer 10.044* First session 28.50 7.285 Second session 28.09 7.091 SD indictes stndrd devition. * P,.05. occsion nother observer proposed shorter tretment durtion. Two orthodontists stted tht LCR ws needed for correct evlution of ll cses. At the second observtion, one still needed the LCR nlysis (in 27 out of 43 cses), nd the other ws stisfied. One reveled tht to perform precise dignosis, dentl csts together with LCR were necessry for ll cses. The others judged the LCR helpful only for some cses, vrying between Clss I nd Clss II (Tble 3). Consensus ws chieved relted to clinicl exmintion. In generl, the orthodontists stressed the need to exmine the ptients personlly. DISCUSSION We performed this study to highlight the usefulness of two-dimensionl cephlometric imging for orthodontic tretment plnning. LCR hs been routinely used since its discovery, lthough mjor concerns rise when ptients re exposed to rdition when it is not clerly justified. According to the ALARA principle, there is need to reduce rdition exposure nd eliminte unnecessry rdiogrphs. We selected the ptients t rndom to llow our smple to be representtive of popultion, rther thn choosing ny prticulr mlocclusion or specific ge. Forty-three ptient files were selected. At first n experimentl observtionl setup ws performed with three orthodontists who evluted five ptient files nd vlidted the questionnire. After tht the study proceeded. Ptient records were reordered t the second observtion so tht orthodontists could not recognize the sequence. We performed two observtion sessions, with minimum of 8 weeks between sessions. Observers hd some differences in terms of their bckground experience. The most experienced observer hd completed 24 yers of prctice, while the lest experienced observer hd only 5 yers of experience. The observer9s bckground plys n importnt role Tble 3. Number of Additionl Informtion Elements Required for Ech Observer in the First nd Second Observtions Additionl Informtion Required First Occsion Second Occsion Observer LCR DC LCR + DC LCR + DC + CBCT LCR Anlysis DC LCR Anlyses + DC Fcil nd LCR Anlysis 1 2 18 16 2 28 10 2 43 27 3 21 2 4 16 11 10 10 8 5 29 7 9 6 27 6 7 28 25 5 7 8 43 9 43* 43* 10 29 29 LCR indictes lterl cephlometric rdiogrphy; DC, dentl csts; nd CBCT, cone bem computed tomogrphy. * Plus intr-orl x-rys, nturl hed position.
210 DURÃO, ALQERBAN, FERREIRA, JACOBS regrds to the necessity of hving dditionl dignostic tools to perform dignosis. It ws suggested tht the need for LCR or its nlysis ws more dependent on bckground rther thn on yers of experience. For exmple, observer 8, who ws the most experienced observer, thought tht LCR would be helpful for ll cses, nd observer 5, with only 6 yers of experience, only judged it necessry to use LCR in 27 of the cses. However, fter viewing the LCR, observer 8 scertined tht cephlometric nlysis ws not necessry. In contrst, observer 6 judged tht the cephlometric nlyses would be helpful. In generl, the biggest complint from orthodontists ws the bsence of (1) clinicl exmintion nd (2) the reson why the ptient sought orthodontic tretment. Tody digitl records re ccepted for dignosis nd tretment plnning for professionl exmintions. Two orthodontists reveled tht in order to perform correct dignosis nd tretment plnning they needed LCR for ll cses. Another orthodontist scertined tht for ll cses the nturl hed position, dentl csts in centric reltion, nd LCR together with clinicl exmintion of the ptient would be importnt to render dignosis nd develop tretment pln. The need for cephlometric nlysis ws lso sserted by some orthodontists. Two orthodontists reveled tht they did not need cephlometric nlysis, while the rdiogrphic exmintion ws useful. One orthodontist required cone bem computed tomogrphy for two cses; in these cses the ptients hd impcted cnines. The questionnire involved 12 questions; the first three questions concerned dignosis. Questions number 4 nd 6 10 relted to tretment plnning. In generl, the percentge of greement ws higher regrding tretment plnning. Some uthors 4,10 hve scertined tht experienced orthodontists cn chieve correct dignosis nd tretment pln without viewing LCR. Other uthors believe tht dignosis bsed on clinicl exmintion together with photogrphs nd dentl csts cn provide sufficient informtion to develop tretment pln. In this study, we found modertely high percentge of greement for tretment plnning between the two sessions. This could suggest tht LCR my not hve n influence on orthodontic tretment plnning. With regrd to skeletl pttern clssifiction, our smple contined 19 ptients with Clss I occlusion; 19 ptients with Clss II occlusion, nd five ptients with Clss III occlusion. For tht reson, it is impossible to scertin tht LCR is not needed for ll ptients since there is gret vrition in mlocclusions. To define strict selection criteri to perform LCR is difficult. Even textbooks do not express this issue very clerly. The indiction for LCR must be constructed on n individul bsis rther thn bsed on generl conditions. 6,8,10 Regrding tretment durtion between the two sessions, the only sttisticlly significnt difference ws found for two observers. Further studies focusing on this subject re encourged. CONCLUSIONS N The results of our study suggest tht the mjority of Portuguese orthodontists judge tht LCR is importnt to producing tretment pln. N Despite tht, it does not seem to hve n influence on orthodontic tretment plnning. REFERENCES 1. Brodbent BH. A new x-ry technique nd its ppliction to orthodonti. Angle Orthod. 1931;1:45 66. 2. Wh PL, Cooke MS, Hägg U. Comprtive cephlometric errors for orthodontic nd surgicl ptients. Int J Adult Orthod Orthognth Surg. 1995;10:119 126. 3. Bumrind S, Frntz RC. The relibility of hed film mesurements. 1. Lndmrk identifiction. Am J Orthod. 1971;60:111 127. 4. Silling G, Ruch MA, Pentel L, Grfinkel L, Hlberstdt G. The significnce of cephlometrics in tretment plnning. Angle Orthod. 1979;49:259 262. 5. Hn UK, Vig KW, Weintrub JA, Vig PS, Kowlski CJ. Consistency of orthodontic tretment decisions reltive to dignostic records. Am J Orthod Dentofcil Orthop. 1991; 100:212 219. 6. Bruks A, Enberg K, Nordqvist I, Hnsson AS, Jnsson L, Svenson B. Rdiogrphic exmintions s n id to orthodontic dignosis nd tretment plnning. Swed Dent J. 1999;23:77 85. 7. Pe EK, McKenn GA, Sheehn TJ, Grci R, Kuhlberg A, Nnd R. Role of lterl cephlogrms in ssessing severity nd difficulty of orthodontic cses. Am J Orthod Dentofcil Orthop. 2001;120:254 262. 8. Nijkmp P, Hbets L, Artmn I, Zentner A. The influence of cephlometrics on orthodontic tretment plnning. Eur J Orthod. 2008;30:630 635. 9. Devereux L, Moles D, Cunninghm SJ, McKnight M. How importnt re lterl cephlometric rdiogrphs in orthodontic tretment plnning? Am J Orthod Dentofcil Orthop. 2011;139:175 181. 10. Atchison K, Luke L, White SC. Contribution of pretretment rdiogrphs to orthodontists decision mking. Orl Surg Orl Med Orl Pthol. 1991;71:238 245.