Cephalometric measurements performed on CBCT and reconstructed lateral cephalograms: a cross-sectional study providing a quantitative approach of differences and bias

Background: Cephalometric analysis is traditionally performed on skull lateral teleradiographs for orthodontic diagnosis and treatment planning. However, the skull flattened over a 2D film presents projection distortions and superimpositions to various extents depending on landmarks relative position. When a CBCT scan is indicated for mixed reasons, cephalometric assessments can be performed directly on CBCT scans with a distortion free procedure. The aim of the present study is to compare these two methods for orthodontic cephalometry. Methods: 114 CBCTs were selected, reconstructed lateral cephalometries were obtained by lateral radiographic projection of the entire volume from the right and left sides. 2D and 3D cephalometric tracings were performed. Since paired t-tests between left and right-side measurements found no statistically significant differences, mean values between sides were considered for both 2D and 3D values. The following measurements were evaluated: PNS-A; S-N; N-Me; N-ANS; ANS-Me; Go-Me; Go-S; Go-Co; SNA, SNB, ANB; Ba boolean AND N; S-N boolean AND PNS-ANS; PNS-ANSGo-Me; S-N boolean AND psi Go-Me. Intraclass correlation coefficients, paired t-test, correlation coefficient and Bland-Altman analysis were performed to compare these techniques. Results: The values of intra- and inter-rater ICC showed excellent repeatability and reliability: the average (+/- SD) intraobserver ICCs were 0.98 (+/- 0.01) and 0.97(+/- 0.01) for CBCT and RLCs, respectively; Inter-rater reliability resulted in an average ICC (+/- SD) of 0.98 (+/- 0.01) for CBCT and 0.94 (+/- 0.03) for RLC. The paired t-tests between CBCT and reconstructed lateral cephalograms revealed that Go-Me, Go-S, PNS-ANS boolean AND Go-Me and S-N boolean AND Go-Me measurements were statistically different between the two modalities. All the evaluated sets of measurements showed strong positive correlation; the bias and ranges for the 95% Limits of Agreement showed higher levels of agreement between the two modalities for unpaired measurements with respect to bilateral ones. Conclusion: The cephalometric measurements laying on the mid-sagittal plane can be evaluated on CBCT and used for orthodontic diagnosis as they do not show statistically significant differences with those measured on 2D lateral cephalograms. For measurements that are not in the mid-sagittal plane, the future development of specific algorithms for distortion correction could help clinicians deduct all the information needed for orthodontic diagnosis from the CBCT scan.