TECHNO BYTES

A new method to measure mesiodistal angulation

and faciolingual inclination of each whole tooth
with volumetric cone-beam computed
tomography images
Hongsheng Tong,a Reyes Enciso,b Dana Van Elslande,c Paul W. Major,d and Glenn T. Sameshimae
Los Angeles, Calif, and Calgary and Edmonton, Alberta, Canada

Introduction: The purpose of this study was to develop a methodology to measure the mesiodistal angulation
and the faciolingual inclination of each whole tooth (including the root) by using 3-dimensional volumetric images
generated from cone-beam computed tomography scans. Methods: A plastic typodont with 28 teeth in ideal oc-
clusion was fixed in position in a dry human skull. Stainless steel balls were fixed to the occlusal centers of the
crowns and to the apices or bifurcation or trifurcation centers of the roots. Cone-beam computed tomography
images were taken and rendered in Dolphin 3D (Dolphin, Chatsworth, Calif). The University of Southern
California root vector analysis program was developed and customized to digitize the crown and root centers
that define the long axis of each whole tooth. Special algorithms were used to automatically calculate the
mesiodistal angulation and the faciolingual inclination of each whole tooth. Angulation measurements
repeated 5 times by using this new method were compared with the true values from the coordinate
measuring machine measurements. Next, the root points of 8 selected typodont teeth were modified to
generate known angulation and inclination values, and 5-time repeated measurements of these teeth were
compared with the known values. Results: Intraclass correlation coefficients for the repeated mesiodistal angu-
lation and faciolingual inclination measurements were close to 1. Comparisons between our 5-time repeated
angulation measurements and the coordinate measuring machine's true angulation values showed 5 teeth
with statistically significant differences. However, only the maxillary right lateral incisor showed a mean
difference that might exceed 2.5
for clinical significance. Comparisons between the 5-repeated
measurements of 8 teeth with known mesiodistal angulation and faciolingual inclination values showed no
statistically significant differences between the measured and the known values, and no measurement had
a 95% confidence interval beyond 1
. Conclusions: We have developed the novel University of Southern
California root vector analysis program to accurately measure each whole tooth mesiodistal angulation and
faciolingual inclination, in a clinically significant level, directly from the cone-beam computed tomography
volumetric images. (Am J Orthod Dentofacial Orthop 2012;142:133-43)

a
Clinical assistant professor, Advanced Orthodontic Program, Herman Ostrow
School of Dentistry, University of Southern California, Los Angeles.
b
Assistant professor, Clinical Dentistry, Division of Endodontics, Oral Surgery and
Orthodontics, Herman Ostrow School of Dentistry, University of Southern
California, Los Angeles.
c
Private practice, Calgary, Alberta, Canada.
d
Professor and chair, Department of Dentistry; head, School of Dentistry, Faculty
of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
e
Associate professor and director, Advanced Orthodontic Program, Herman
Ostrow School of Dentistry, University of Southern California, Los Angeles.
The University of Southern California has filed a provisional patent application
on our behalf to protect our potential intellectual right for developing the meth-
odology used in this study to measure the mesiodistal angulation and the facio-
lingual inclination of each whole tooth.
Reprint requests to: Hongsheng Tong, 20360 Via Manresa, Yorba Linda, CA
92887; e-mail, drhstong@yahoo.com.
Submitted, June 2011; revised and accepted, December 2011.
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.12.027
T
he basic objectives of orthodontic treatment are to
obtain proper positions of all teeth by using vari-
ous orthodontic appliances, to form a functional
and stable occlusion, and to display the teeth in proper
relationships to one another and in harmony with
the maxillofacial hard and soft tissues after treatment.
Six parameters describe each tooth location in
3-dimensional space. Three are positional (mesiodistal,
faciolingual, and occlusogingival), and 3 are angular
(mesiodistal angulation, faciolingual inclination, and
axial rotation). Nearly half a century ago, Andrews1,2
studied 120 patients with optimal occlusions and
obtained the positional and angular norms for all teeth
by measuring their crowns on the study models.
Various types of preadjusted appliances that are used
133
134
by most orthodontists today are, to a certain degree,
derived from the original straight-wire appliances he
developed based on these crown norms.1-4 However,
although 4 of the 6 parameters defining tooth
positions are dictated by the crowns and are easy to
monitor clinically, later research has shown that
crowns might not provide clear indications for the
angulation and the inclination of the whole teeth,
including the roots.5-8 Moreover, straight-wire tech-
niques rely heavily on precise bracket positioning during
initial bonding, and yet orthodontists at various experi-
ence levels have found difficulties in accurately placing
brackets directly on patients' teeth or even indirectly
on the teeth of stone models.9-12 So far, the roots that
constitute about half of the whole tooth have been
mostly ignored. It is speculated that the roots might
also need to be assessed to achieve ideal whole tooth
angulation and inclination.
Traditionally, panoramic x-rays have been used at the
initial, progress, and finishing stages of orthodontic
treatment to diagnose, monitor, and finalize the angula-
tions of the teeth.13,14 However, studies have indicated
that panoramic x-rays have distortions and do not
reflect the true 3-dimensional teeth angulations because
the x-ray beam is not always orthogonal to the target
teeth.15-18 For faciolingual inclinations, the only
assessment tool available is the lateral cephalogram for
the maxillary and mandibular central incisors.19,20 A
posteroanterior cephalogram might capture the
faciolingual inclinations of a few molars, but the image
quality is usually poor and rarely used.
As we know, the position of teeth is a 3-dimensional
issue. Andrews1-3 did not measure the angulation and
the inclination of teeth from 2-dimensional x-rays but
from study models that are 3-dimensional. Fortunately,
the development and use of cone-beam computed to-
mography (CBCT) in orthodontics in recent years have
allowed us see the roots of teeth in 3 dimensions as
well. This lets us accurately evaluate the mesiodistal an-
gulation and the faciolingual inclination of each whole
tooth (crown and root) rather than just the crown. How-
ever, there is no clinically useful tool currently available
to systemically measure whole tooth angulation and in-
clination in 3 dimensions. Van Elslande et al21 had to
construct 2-dimensional panoramic-like images from
3-dimensional CBCT images to measure the angulation
of the typodont teeth. They compared these measure-
ments with those taken directly from a coordinate mea-
suring machine, the gold standard 3-dimensional
measuring device. They suggested that the constructed
images might be better than conventional panoramic ra-
diographs in assessing root angulations, although the
measurements were still off significantly from the true
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tong et al
3-dimensional coordinate measuring machine's mea-
surements for a few teeth. The coordinate measuring
machine was also used in an earlier study by Garcia-
Figueroa et al18 to show the effect of changing the facio-
lingual inclination of a few selected teeth on their mesio-
distal angulation measurements. However, the gold
standard coordinate measuring machine cannot be
used on patients, since the tip of the machine's probe
cannot be brought in contact with the patients’ root
apices.
We have collaborated with the Dolphin company
(Chatsworth, Calif) and developed the University of
Southern California (USC) root vector analysis program
in the Dolphin 3D module to directly measure the mesio-
distal angulation and the faciolingual inclination of each
whole tooth using CBCT volumetric images. To test the
validity of our methodology, we also collaborated with
the research group from the University of Alberta, Ed-
monton, Alberta, Canada, who provided the typodont
CBCT images and the coordinate measuring machine's
mesiodistal angulation measurement data for the typo-
dont teeth to compare with our results.
MATERIAL AND METHODS
We measured the mesiodistal angulation of the typo-
dont teeth with the coordinate measuring machine (Faro
International, Lake Mary, Fla). The typodont was based
on a modification of the model previously reported by
McKee et al16 and Garcia-Figueroa et al.18 It consisted
of transparent plastic anatomic typodont maxilla and
mandible (Kilgore International, Coldwater, Mich) with
synthetic teeth in idealized occlusion from the second
molar to the second molar. As shown by Van Elslande
et al,21 the typodont was mounted on a dry human skull.
Stainless steel balls (Small Parts, Miramar, Fla), 1.58 mm
in diameter, were placed at the approximate mesiodistal
and faciolingual centers of the occlusal surfaces, and at
the approximate centers of the root apices for single-
rooted teeth or the centers of the bifurcation or trifurca-
tion at the level of the root apices for multi-rooted teeth.
A line connecting the 2 centers on each tooth repre-
sented its long axis.
The coordinate measuring machine was used to de-
termine the actual mesiodistal angular measurement of
each whole tooth with reference to the archwires that
were held in place on the plastic molds of the maxilla
and the mandible at approximately the middle of the
roots. A mesiodistal plane was created for each tooth
that was perpendicular to the horizontal (archwire)
plane. This tooth-specific reference plane passed
through the mesial and distal interproximal points
marked on the archwires with crimpable stops. The
Tong et al 135

Fig 1. Setting up the global coordination system for the maxillary arch: the midsagittal plane (red)
evenly dividing the right and left sides, the coronal plane (green) at the buccal groves of the maxillary
right and left first molars, and the axial plane (blue) at the maxillary archwire level.

mesiodistal angulation of a tooth was the measurement
of the angulation between the projection of the tooth's
long axis on the mesiodistal plane and the vertical line.
One investigator (D.V.E.) made repeated measure-
ments on 5 separate occasions, 5 days apart, and the in-
traclass correlation coefficient values were calculated to
determine the reliability of the coordinate measuring
machine's angulation measurements. The coordinate
measuring machine was reported by the manufacturer
to be accurate to within 0.013 mm. For angular mea-
surements, the machine was found to be accurate to
within 0.031
. The average of the 5-time repeated coor-
dinate measuring machine's angulation measurements
were used as the true values.
The typodont teeth's mesiodistal angulations and fa-
ciolingual inclinations were also measured by using the
custom USC root vector analysis program. For the
CBCT scan of the same typodont used above, a NewTom
3G volume scanner (AFP, Elmsford, NY) was used ac-
cording to the manufacturer’s instructions as shown
also by Van Elslande et al.21 Twenty-five independent
images were obtained from separate CBCT scans for
the previous study, and 5 of them were randomly
selected and imported into the Dolphin Imaging 3D pro-
gram. The USC root vector analysis program was devel-
oped in the Dolphin 3D module to measure both the
mesiodistal angulation and the faciolingual inclination
of each whole tooth as shown below.
Once the typodont digital imaging and communica-
tions in medicine (DICOM) data were imported into Dol-
phin 3D, a 3-dimensional global coordinate system was
first generated for the proper orientation of the head and
the maxillofacial structures. This coordinate system in-
cluded the midsagittal plane, the coronal plane, and
the axial plane, each perpendicular to the other 2 planes
(Fig 1). The midsagittal plane evenly divided the right
and the left halves of the skull; the coronal plane passed
through the maxillary first molar buccal grooves on both
sides, and the axial plane was the archwire plane. Since
the maxillary and mandibular teeth had separate arch-
wire planes, there were also 2 separate 3-dimensional
global coordinates: 1 saved for the maxilla, and 1 saved
for the mandible.
The digitization of each tooth's long axis was done in
all 3 plane views, each perpendicular to the other 2
views. Parallel movements of the sagittal, coronal, and

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136 Tong et al

Fig 2. Locating the maxillary right central incisor crown point before digitization: parallel movements of
the sagittal (red), coronal (green), and axial (blue) planes were made to intersect at the center of the
stainless steel ball representing the tooth's crown point.

axial planes were made so that each would pass through
the center of the white stainless steel marker represent-
ing either the crown or the root point of each tooth
(Figs 2 and 3). A red dot was digitized at the intersection
of the 3 perpendicular planes in 1 of the 3 plane views; it
would also appear automatically in the other 2 views.
The order of digitization was from the maxillary right
second molar to the maxillary left second molar, and
from the mandibular left second molar to the mandibu-
lar right second molar. Figure 4 shows all the white
stainless steel markers replaced by the red digitization
points. The green lines represented the long axes of
the teeth after the digitization was completed in both
arches.
Next we digitized the archwires. For the maxillary
arch, the global coordinate saved for the maxillary teeth
was restored first, and the maxillary archwire was digi-
tized in the axial plane view set at the archwire level
(Fig 5). Four teeth on the right side were digitized along
the archwire: midincisor, canine, second premolar, and
second molar. The software program would add the mir-
ror image of the right side half arch to the left side, con-
structing a symmetrical arch form. The mandibular
archwire was digitized in the same way after the global
coordinate saved for the mandibular arch was restored.
Then the tooth-specific coordinate system for the
mesiodistal angulation and the faciolingual inclination
measurements was set up. Once the arch form was
digitized, the custom USC root vector analysis program
would automatically construct another 3-plane coordi-
nate system consisting of multiple coordinates, each
specific for only 1 tooth for its mesiodistal angulation
and faciolingual inclination measurements (Fig 5): the
transverse plane was the same axial plane at either the
maxillary or the mandibular archwire level as in the
global coordinate system; the straight green line repre-
sented the faciolingual plane that passed through each
tooth crown point (dark blue dot) and was perpendicular
to the archwire; the short light blue line represented the
mesiodistal plane that also passed through each tooth
crown point, but was perpendicular to the faciolingual
plane. The mesiodistal angulation and the faciolingual
inclination were measured for each tooth in its corre-
sponding tooth-specific coordinate.
As shown in Figure 6, A, the mesiodistal angulation
was measured from the projection of the tooth's long

July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tong et al 137

Fig 3. Digitization of the maxillary right central incisor root point: parallel movements of the sagittal
(red), coronal (green), and axial (blue) planes were made to intersect at the center of the stainless steel
ball representing the tooth's root point, and it was digitized (red dots).

axis on the mesiodistal plane to the vertical line formed

by the intersection of the mesiodistal and faciolingual
planes. If the root center was distal to the crown center,
the measurement would be positive; otherwise, it would
be negative. The faciolingual inclination was measured
from the projection of the tooth's long axis on the facio-
lingual plane to the vertical line formed by the same
intersection of the mesiodistal and faciolingual planes
(Fig 6, B). If the root center was lingual to the crown cen-
ter, the measurement would be positive; otherwise, it
would be negative.
At this point, the custom USC root vector analysis
program would use algorithms to measure the mesiodis-
tal angulation and the faciolingual inclination values for
all teeth automatically.
Teeth with known mesiodistal angulation and facio-
lingual inclination values were measured. The same 5 ty-
Fig 4. All crown and root points have been replaced by
podont images above were used again, except that the red digitization dots, and the teeth's long axes are shown
root points of the maxillary right first molar and first pre- in green.
molar, the maxillary left central incisor and second mo-
lar, the mandibular right second molar and canine, and the apices of these teeth but at locations defined
the mandibular left lateral incisor and first molar were through the following three steps (Fig 7): (1) in the axial
not digitized at the stainless steel balls representing slice view (Fig 7, A) at the crown point level, the image

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
138
Fig 5. The maxillary arch on the right side was digitized
based on 4 points along the archwire relative to the follow-
ing tooth positions: midincisor, right canine, right second
premolar, and right second molar (yellow dots). The left
side half arch was the mirror image of the right side half.
The tooth-specific coordinate system was based on the
arch form and the crown point of each tooth: the trans-
verse plane was the maxillary archwire plane; the faciolin-
gual plane (long straight green line) passed each tooth
crown point (dark blue dot) and was perpendicular to
the maxillary arch; the mesiodistal plane (short light
blue line) was perpendicular to the faciolingual plane at
the crown point (dark blue dot) of each tooth.
was rotated so that for the tooth to be digitized, the fa-
ciolingual direction was shown vertically and the mesio-
distal direction was shown horizontally; (2) in the
mesiodistal (Fig 7, B) or faciolingual (Fig 7, C) slice
view, the transverse plane at the crown point level was
moved 20 mm apically; and (3) in the mesiodistal slice
view (Fig 7, B), the faciolingual plane was moved 5
mm distally, and in the faciolingual slice view (Fig 7,
C), the mesiodistal plane was moved 10 mm lingually.
After these parallel movements of the reference planes,
the 3-plane intersection would be at a point that was
20 mm apical, 10 mm lingual, and 5 mm distal from
the crown point. The root point was digitized at this in-
tersection. Trigonometric calculation should give the
tooth 14.04
of mesiodistal angulation and 26.57
of fa-
ciolingual inclination. For the maxillary right first molar
and the mandibular left lateral incisor, the root points
were placed mesially instead of distally to reflect their
distal angulation; for the 2 mandibular molars, the
root points were placed buccally instead of lingually to
reflect their lingual crown inclinations.
Statistical analysis
To ensure that the measurement methodology de-
scribed above was reliable, the principal investigator
(H.T.) randomly chose 5 images from the 25 independent
July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tong et al
scans of the same typodont obtained from the University
of Alberta. Digitizations were done a week apart, and
intraclass correlation coefficients for the mesiodistal an-
gulation and faciolingual inclination measurements
were calculated.
One-sample t tests were used to check for statistically
significant differences between our 5-time repeated me-
siodistal angulation measurements and the coordinate
measuring machine's true mesiodistal angulation values
for each tooth. The a level was adjusted to 0.05/28 5
0.001786 for the multiple t tests based on the Bonferroni
adjustment. One-sample t tests were also used to com-
pare the 5-time repeated mesiodistal angulation and
faciolingual inclination measurements with the given
mesiodistal angulation and faciolingual inclination
values for each of the 8 selected teeth. The a level was
adjusted to 0.05/8 5 0.00625.
RESULTS
The intraclass correlation coefficients for the 5-time
repeated mesiodistal angulation and faciolingual incli-
nation measurements with our USC root vector analysis
in Dolphin 3D were 0.998 and 1.000, respectively, with
95% confidence intervals of 0.996 to 0.999 for the an-
gulations, and 0.999 to 1.000 for the inclinations. The
intraclass correlation coefficient for the 5 repeated an-
gulation measurements with the coordinate measuring
machine was 0.995 with a 95% CI of 0.991 to 0.997.
Differences between our angulation measurements
and the coordinate measuring machine's true angula-
tion values were calculated, and the 5-time mean differ-
ences, the standard deviations of the mean differences,
and the 95% confidence intervals are shown in Table I,
along with the P values from the 1-sample t test for
each tooth. Five teeth (maxillary right lateral incisor
and canine, maxillary left first premolar, and mandibular
left canine and first premolar) of the 28 teeth showed
statistically significant differences between our angula-
tion measurements and the coordinate measuring
machine's true values. The mean differences of our
5-time measurements from the coordinate measuring
machine's true values and the 95% confidence intervals
for these teeth were the following: maxillary right lateral
incisor, 2.15
(95% CI, 1.439
-2.861
); maxillary right
canine, 0.876
(95% CI, 0.585
-1.168
); maxillary left
first premolar, 1.098
(95% CI, 0.914
-1.282
); mandib-
ular left canine, 1.97
(95% CI, 1.486
-2.454
); and
mandibular left first premolar, 1.286
(95% CI, 0.97
-
1.603
). However, only the maxillary right lateral incisor
measurement might be close to 2.5
for clinical signifi-
cance. Faciolingual inclination measurements were not
made with the coordinate measuring machine.
Tong et al 139

Fig 6. A, Mesiodistal angulation was measured in the mesiodistal plane and defined as the angle formed
by the projection of the tooth's long axis (green line) and the red line that represented the faciolingual plane
and the mesiodistal plane intersection; B, faciolingual inclination was measured in the faciolingual plane
and defined as the angle formed by the projection of the tooth's long axis (short green line) and the long
green line that represented the mesiodistal plane and the faciolingual plane intersection. The blue line in A
and B represented transverse planes that were parallel to the occlusal plane.

For the teeth with known mesiodistal angulation and
faciolingual inclination values, measurements were also
done 5 times, and the intraclass correclation coefficient
was 1 for both the angulation and the inclination. Dif-
ferences between measured values and the known values
were calculated, and the 5-time mean differences, stan-
dard deviations of the mean differences, and 95% con-
fidence intervals are shown in Table II, along with the
P values from the 1-sample t test for each tooth. None
of the 8 teeth for both angulation and inclination
showed any statistically significant difference between
the measured and the known values. None of the teeth
had a 95% confidence interval above 1
.
DISCUSSION
High-quality orthodontic treatment requires that all
teeth are placed in their proper positions for a stable
and functional occlusion and an esthetic appearance after
treatment. The focus of the specialty of orthodontics has
been mostly on the positions of the crowns of teeth, and
little attention has been given to the roots.5-8 This is
because the positions of the roots rarely pose esthetic or
functional problems, since they are mostly invisible and
away from the occlusal contacts. Although the correct
positioning of the roots in the basal bone might reduce
the amount of relapse, however, research has indicated
that long-term stability cannot be expected even with
high-quality orthodontic finishing.22-25 Even a naturally
occurring normal occlusion might not be maintained
for life.26 However, orthodontists still strive to obtain
proper root positions for the best treatment outcome.
Since the use of preadjusted appliances does not guaran-
tee ideal root positions, most orthodontists take initial,
progress, and final panoramic radiographs to check for
root alignment in addition to checking for pathology.
This is because minor crown tipping that might have
evaded visual inspection can be magnified in the mis-
alignment of the roots and become easily detectable.13,14
Until just recently, there have been only a few radio-
graphic methods to check root position, each with some
problems. To measure the mesiodistal angulation of
each tooth accurately, the x-ray beam must be aimed at
the target tooth orthogonally. Periapical radiographs can-
not be taken with an orthogonal view of multiple teeth on
a curved dental arch at the same time. Panoramic x-rays,
although designed to follow the curvature of the dental
arch, might show orthogonal images of only a few teeth.27
Various studies have indicated its limitations, especially in
the canine and first premolar areas.16-18 However, the
American Board of Orthodontics still recommends the
use of panoramic x-rays in assessing the angulation of
the roots.28 General root parallelism is required, and
points are deducted if the roots of adjacent teeth are
not parallel or come in contact with one another.
Exceptions have been made for the canine areas recently

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
140 Tong et al

Fig 7. Digitization of the root point for the known mesiodistal angulation and faciolingual inclination. A,
Set the axial view at the maxillary archwire level, then move the transverse plane to the crown point
level for the maxillary right first premolar to be digitized, rotate the image in the axial view so that the
faciolingual direction of the tooth was shown vertically and the mesiodistal direction was shown hori-
zontally. B, The mesiodistal plane view showing that the transverse plane (blue) was moved 20 mm
apically, and the faciolingual plane (red) was moved 5 mm distally from the crown point. C, The facio-
lingual plane view showing that the mesiodistal plane (green) was moved 10 mm lingually. The inter-
section of the transverse plane (blue), the mesiodistal plane (green), and the faciolingual plane (red)
was where the root point was digitized. D, Diagram showing the 3-dimensional relationship: a, b, c,
d, and g each at a corner of a cubic with each side 20 mm long. The center of the crown is placed at
point c. cd points mesiodistally; cg points faciolingually, and cb points occlusogingivally; cb, 20 mm api-
cal; be, 5 mm distal; bf, 10 mm lingual; r, designated root point; and yellow arrow, presumed long axis of
the tooth. The mesiodistal angulation a and the faciolingual inclination b for the tooth were calculated to
be 14.04
and the 26.57
, respectively.
(www.americanboardortho.com). The American Board of obtained from CBCT scans have been shown to display
Orthodontics does not have special requirements for the dentofacial structures in a 1:1 ratio, and distortions,
faciolingual inclination of the roots. if any, are clinically insignificant.29-31 Van Elslande
The assessments of the root or the whole tooth angu- et al21 measured the angulation of the typodont teeth
lation and inclination really require that we see the from the panoramic-like images constructed from
whole tooth in 3 dimensions. A coordinate measuring CBCT scans and compared them with the coordinate
machine has been used to measure the angulation16,21 measuring machine's measurements. It was concluded
and the inclination18 of typodont teeth directly. Al- that the constructed panoramic-like images were more
though considered a gold standard 3-dimensional mea- accurate than the conventional panoramic radiographs
suring device, the coordinate measuring machine cannot in assessing tooth angulation. Although this new tech-
be used on patients clinically, since direct contact of the nique takes care of the nonorthogonal problem of the
root apices of the patients’ teeth by the machine's probe conventional panoramic radiograph, other problems
is not possible. In recent years, CBCT technology has arise: image formation is 1:1 only at the center of the se-
been used in orthodontics, and the volumetric images lected arch trough, structures lingual to the center

July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tong et al 141

Table I. Comparison between the USC mesiodistal an- Table II. Comparison between the USC mesiodistal
gulation measurements and the coordinate measuring angulation and faciolingual inclination measurements
machine's true values of the typodont teeth and the known values of the typodont teeth
Mean 95% CI 95% CI
Tooth difference (
) SD (upper and lower) P value* Mean difference (
) SD (upper and lower) P value*
UR 1 0.309 0.691 0.548 1.167 0.373 Mesiodistal angulation
UR 2 2.150 0.573 2.861 1.439 0.001* UR 4 0.16 0.335 0.576 0.256 0.345
UR 3 0.876 0.235 1.168 0.585 0.001* UR 6 0.40 0.344 0.027 0.827 0.060
UR 4 0.339 0.300 0.034 0.711 0.065 UL 1 0.46 0.370 0.920 0.000 0.050
UR 5 0.677 0.647 0.126 1.480 0.079 UL 5 0.32 0.396 0.812 0.172 0.145
UR 6 0.455 0.295 0.088 0.821 0.026 LR 3 0.04 0.356 0.403 0.483 0.814
UR 7 0.667 0.336 1.084 0.249 0.011 LR 7 0.32 0.270 0.016 0.656 0.057
UL 1 0.733 0.618 0.035 1.500 0.057 LL 2 0.08 0.217 0.349 0.189 0.456
UL 2 0.365 0.730 0.541 1.272 0.326 LL 6 0.08 0.270 0.416 0.256 0.544
UL 3 0.572 0.377 1.040 0.104 0.027 Faciolingual inclination
UL 4 1.098 0.148 0.914 1.282 \0.001y UR 4 0.19 0.563 0.889 0.509 0.492
UL 5 0.112 0.321 0.287 0.510 0.479 UR 6 0.35 0.179 0.572 0.128 0.012
UL 6 0.571 0.397 0.078 1.065 0.032 UL 1 0.19 0.438 0.734 0.354 0.387
UL 7 0.457 0.313 0.846 0.069 0.031 UL 5 0.13 0.305 0.509 0.249 0.394
LR 1 0.295 0.415 0.810 0.220 0.187 LR 3 0.07 0.472 0.516 0.656 0.757
LR 2 1.300 0.650 2.107 0.494 0.011 LR 7 0.05 0.593 0.687 0.787 0.860
LR 3 1.356 0.432 1.893 0.819 0.002 LL 2 0.13 0.283 0.221 0.481 0.362
LR 4 1.018 0.390 0.534 1.502 0.004 LL 6 0.17 0.324 0.232 0.572 0.306
LR 5 0.045 0.311 0.431 0.342 0.764
U, Upper (maxillary); L, lower (mandibular); R, right; L, left; 1, cen-
LR 6 0.484 0.329 0.892 0.076 0.030
tral incisor; 2, lateral incisor; 3, canine; 4, first premolar; 5, second
LR 7 0.247 0.540 0.918 0.424 0.365
premolar; 6, first molar; 7, second molar.
LL 1 0.216 0.374 0.249 0.681 0.266
*One-sample t test: level of a 5 0.05/8 5 0.00625 (Bonferroni ad-
LL 2 0.819 0.901 1.938 0.300 0.112
justment for multiple comparisons).
LL 3 1.970 0.390 2.454 1.486 \0.001y
LL 4 1.286 0.255 1.603 0.970 \0.001y
even though minor but statistically significant differ-
LL 5 0.023 0.500 0.598 0.644 0.924
LL 6 0.407 0.396 0.899 0.085 0.083 ences existed for some teeth between our measurements
LL 7 0.144 0.606 0.608 0.896 0.623 and those of the machine. We were unable to explain
U, Upper (maxillary); L, lower (mandibular); R, right; L, left; 1, cen-
these differences, which appeared almost randomly
tral incisor; 2, lateral incisor; 3, canine; 4, first premolar; 5, second and never happened in the same teeth on the contralat-
premolar; 6, first molar; 7, second molar. eral side. Our measurements of selected typodont teeth
*One-sample t test: level of a 5 0.05/28 5 0.001786 (Bonferroni with known angulation and inclination values were
adjustment for multiple comparisons); yStatistically significant dif- also highly accurate. A number of factors might have
ference.
contributed to this high precision in our methodology.
Taking orthogonal views of the teeth and digitization
trough are stretched, and structures facial to the center of the crown and root points at the intersection of 3
trough are shrunk. The amount of distortion is also re- perpendicular planes simultaneously helped to ensure
lated to the amount of faciolingual inclination, since precision; the special algorithms used to set up the
a tooth with a large inclination would have its root far- tooth-specific coordinate system for automatic mea-
ther from the center trough. As for measuring the facio- surements was another way to reduce human errors to
lingual inclination of each tooth in 3 dimensions, no a minimum. Our study showed that the reliability and
clinical tools have been available. With the help from the accuracy of our program were comparable to those
Dolphin, we have developed the USC root vector analysis of the coordinate measuring machine's gold standard.
program to measure each whole tooth's mesiodistal an- This new tool can be used to measure the mesiodistal
gulation and faciolingual inclination directly from the angulation and the faciolingual inclination of each whole
CBCT volumetric images. tooth in patients with normal occlusion, an important
The test of our custom program with the typodont step toward establishing a clinical standard that could
teeth showed that our angulation and inclination mea- provide guidance for orthodontic finishing. Such stan-
surements in Dolphin 3D were highly reproducible as in- dards might be helpful in designing new orthodontic ap-
dicated by the high intraclass correlation coefficients. pliances that will no longer ignore the roots. Some new
Our angulation measurements also compared well with treatment systems such as Invisalign (Align Technology,
the coordinate measuring machine's measurements, San Jose, Calif), SureSmile (Orametrix, Richardson, Tex),

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
142
Incognito (3M-Unitek, Monrovia, Calif), and Insignia
(Ormco, Orange, Calif) might benefit from this as well
by being root conscious while setting up the teeth virtu-
ally before treatment. In addition, this new tool can also
be used to compare the outcomes of various treatment
modalities: eg, surgical treatment vs camouflage, and ex-
traction vs nonextraction. We can also compare the
norms of different ethnic groups to set ethnic-specific
goals for patients with different backgrounds.
Our custom program has certain limitations. It can-
not be used for patients with malocclusions, since set-
ting up the global coordinate system and digitization
of the maxillary and mandibular dental arches require
the subjects to have normal or near normal occlusions.
Modifications to the program might need to be made
if malocclusions, especially asymmetries, are present.
Another potential limitation might be that the
3-dimensional image quality of the patients’ teeth is
not as good as those of the stainless steel balls used
in this typodont study because of more complicated
overlapping of structures, restorations, patient move-
ment, and so on. Radiation safety should always be
a concern. Exposing patients even to a slightly ele-
vated amount of radiation might be justified only if
its use leads to better treatment; this still remains to
be seen. However, the newer generation of CBCT de-
vices has already shown promising improvement in im-
age resolution with reduced radiation.
CONCLUSIONS
We developed the custom USC root vector analysis
program to measure the mesiodistal angulation and
the faciolingual inclination of each whole tooth from
a typodont.
1. Measurements made with the USC root vector anal-
ysis program compared well with the gold standard
of the coordinate measuring machine's measure-
ments.
2. The USC root vector analysis program could also
measure accurately the teeth with known values of
angulation and inclination.
3. The USC root vector analysis program is valid and
can be applied to patients clinically.
We thank Swann Liao for writing the custom USC
root vector analysis program, Carlos Flores-Mir for a crit-
ical review of this article, and Victoria Rodriguez for
assistance with CBCT.
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