Pisha Pittayapat

Human dental age estimation using third molar developmental stages: Accuracy of age predictions not using country specific information.

Unquestionable forensic age investigations are based on statistical models constructed on a sample containing subjects of identical origin as the examined individual. In cases where corresponding models are unavailable, the established report has to describe the possible effects of this unrelated information on the predicted age outcome. The aim of this study is to collect country specific databases of third molar development and to verify how the related dental age estimations are influenced if we were to use dental developmental information only from Belgium or from all collected countries together. Data containing third molar developmental stages scored following Gleiser and Hunt (modified by Köhler) were collected from 9 country specific populations (Belgium, China, Japan, Korea, Poland, Thailand, Turkey, Saudi-Arabia and South-India). Age predictions were obtained from a training dataset and validated on a test dataset. Bayes rule using the repeated third molar scores is applied to get age predictions and prediction intervals. Three age predictions were compared for males and females separately. For the first prediction, the training dataset contains only Belgian subjects. For the second prediction, the training dataset for each country consists only of subjects of the country itself. For the final prediction, subjects from all countries are pooled into one common training dataset. Besides the (absolute) difference between the chronological age and the predicted age, specific interest lies in the juvenile-adult distinction. In the age range from 16 to 22 years 6982 subjects (3189 male and 3793 female) were analyzed. Using information on third molar development from Belgium compared to information from the country specific databases hardly increased the mean absolute differences (MAD) and mean squared errors (MSE): the MAD and MSE increased on average with 0.5 and 2.5 months with maximal increases of, respectively 1.6 and 7.3 months. Using information from all countries pooled compared to country specific information provided even on average negligible increases (0.05 and 0.2 months for MAD and MSE, respectively). For the juvenile-adult discrimination, using information from all countries instead of country specific information yielded comparable performances. Using Belgium instead of country specific information increased the percentage of correctly identified juveniles, but decreased the percentage of correctly identified adults. The adult-juvenile discrimination based on information used from Belgium provides judicially the best applied reference.

Estimating Age of Majority on Third Molars Developmental Stages in Young Adults from Thailand Using a Modified Scoring Technique

Abstract:  The aim of this study was to achieve a referral database for dental age estimation of unaccompanied minors of Thai nationality. A total of 1199 orthopantomograms were collected from original Thai women and men equally divided in age categories between 15 and 24 years. On the radiographs, the developmental stage of the third molars was scored applying a modified scoring technique. Inter‐ and intra‐observer reliabilities were tested using kappa statistics. Correlation between the scores of all four wisdom teeth and left–right symmetry were evaluated with Pearson’s correlation coefficient. Student’s t‐test on asymmetry was performed and regression formulas were calculated. The present database was the first to assemble third molar developmental scores on radiographs of Thai individuals and provides more appropriate dental age estimation of unaccompanied Thai minors. Future research on similar databases of different nationalities worldwide may expose ethnical influences on dental development.

Three‐dimensional cephalometric analysis in orthodontics: a systematic review

CONTEXT The scientific evidence of 3D cephalometry in orthodontics has not been well established. OBJECTIVE The aim of this systematic review was to evaluate the evidence for the diagnostic efficacy of 3D cephalometry in orthdontics, focusing on measurement accuracy and reproducibility of landmark identification. DATA SOURCES PubMed, EMBASE and the Cochrane library (from beginning to March 13, 2012) were searched. Search terms included: cone-beam computed tomography; tomography, spiral computed; imaging, three-dimensional; orthodontics. STUDY SELECTION Two reviewers read the retrieved articles and selected relevant publications based on pre-established inclusion criteria. The selected publications had to elucidate the hierarchical model of the efficacy of diagnostic imaging systems by Fryback and Thornbury. DATA EXTRACTION The data was then extracted according to two protocols, which were based on the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Next, levels of evidence were categorized into 3 groups: low, moderate and high evidence. DATA SYNTHESIS 571 publications were found by database search strategies and 50 additional studies by hand search. A total of 35 publications were included in this review. CONCLUSIONS Limited evidence for the diagnostic efficacy of 3D cephalometry was found. Only 6 studies met the criteria for a moderate level of evidence. Accordingly, this systematic review reveals that there is still need for methodologically standardized studies on 3D cephalometric analysis.

A split-mouth comparative study up to 16 years of two screw-shaped titanium implant systems.

INTRODUCTION Many studies have dealt with the clinical outcome of oral implants, yet none applied a randomized split-mouth design for a long-term follow-up of similar implant systems. AIM To evaluate two oral implant systems with different surface characteristics in a randomized split-mouth design and to radiologically analyse peri-implant bone level and density over an up to 16-year period. MATERIALS AND METHODS The study comprised clinical and radiographic records of 18 partially edentulous patients treated with both implant types randomly placed in either left or right jaw sides. Outcome was evaluated over time. RESULTS Clinical and radiographic parameters showed no significant differences over time for both systems. Ten years after implant placement, a significantly increasing peri-implant bone density was noted, while Periotest values were found to be significantly decreasing. Fifteen years after implant loading, mean bone loss was 0.02 mm (range -1.15 to 1.51; SD 0.45) for Astra Tech® implants (n=24) and 0.31 mm (range -0.98 to 2.31; SD 0.69) for Brånemark® implants (n=23). CONCLUSIONS The study failed to demonstrate significant differences in the outcome of the peri-implant bone for two implant systems with different surface characteristics. The marginal bone level around oral implants changed <0.5 mm after 15 years of loading.

Accuracy of linear measurements using three imaging modalities: two lateral cephalograms and one 3D model from CBCT data

BACKGROUND The aim of this study was to evaluate the accuracy of linear measurements on three imaging modalities: lateral cephalograms from a cephalometric machine with a 3 m source-to-mid-sagittal-plane distance (SMD), from a machine with 1.5 m SMD and 3D models from cone-beam computed tomography (CBCT) data. METHODS Twenty-one dry human skulls were used. Lateral cephalograms were taken, using two cephalometric devices: one with a 3 m SMD and one with a 1.5 m SMD. CBCT scans were taken by 3D Accuitomo® 170, and 3D surface models were created in Maxilim® software. Thirteen linear measurements were completed twice by two observers with a 4 week interval. Direct physical measurements by a digital calliper were defined as the gold standard. Statistical analysis was performed. RESULTS Nasion-Point A was significantly different from the gold standard in all methods. More statistically significant differences were found on the measurements of the 3 m SMD cephalograms in comparison to the other methods. Intra- and inter-observer agreement based on 3D measurements was slightly better than others. LIMITATIONS Dry human skulls without soft tissues were used. Therefore, the results have to be interpreted with caution, as they do not fully represent clinical conditions. CONCLUSIONS 3D measurements resulted in a better observer agreement. The accuracy of the measurements based on CBCT and 1.5 m SMD cephalogram was better than a 3 m SMD cephalogram. These findings demonstrated the linear measurements accuracy and reliability of 3D measurements based on CBCT data when compared to 2D techniques. Future studies should focus on the implementation of 3D cephalometry in clinical practice.

Validity of 2D lateral cephalometry in orthodontics: a systematic review

Lateral cephalometric radiography is commonly used as a standard tool in orthodontic assessment and treatment planning. The aim of this study was to evaluate the available scientific literature and existing evidence for the validation of using lateral cephalometric imaging for orthodontic treatment planning. The secondary objective was to determine the accuracy and reliability of this technique. We did not attempt to evaluate the value of this radiographic technique for other purposes. A literature search was performed using specific keywords on electronic databases: Ovid MEDLINE, Scopus and Web of Science. Two reviewers selected relevant articles, corresponding to predetermined inclusion criteria. The electronic search was followed by a hand search of the reference lists of relevant papers. Two reviewers assessed the level of evidence of relevant publications as high, moderate or low. Based on this, the evidence grade for diagnostic efficacy was rated as strong, moderately strong, limited or insufficient. The initial search revealed 784 articles listed in MEDLINE (Ovid), 1,034 in Scopus and 264 articles in the Web of Science. Only 17 articles met the inclusion criteria and were selected for qualitative synthesis. Results showed seven studies on the role of cephalometry in orthodontic treatment planning, eight concerning cephalometric measurements and landmark identification and two on cephalometric analysis. It is surprising that, notwithstanding the 968 articles published in peer-reviewed journals, scientific evidence on the usefulness of this radiographic technique in orthodontics is still lacking, with contradictory results. More rigorous research on a larger study population should be performed to achieve full evidence on this topic.

Optimization of dental CBCT exposures through mAs reduction

OBJECTIVES To investigate the effect of tube current-exposure time (mAs) reduction on clinical and technical image quality for different CBCT scanners, and to determine preliminary minimally acceptable values for the mAs and contrast-to-noise ratio (CNR) in CBCT. METHODS A polymethyl methacrylate (PMMA) phantom and an anthropomorphic skull phantom, containing a human skeleton embedded in polyurethane, were scanned using four CBCT devices, including seven exposure protocols. For all protocols, the mAs was varied within the selectable range. Using the PMMA phantom, the CNRAIR was measured and corrected for voxel size. Eight axial slices and one coronal slice showing various anatomical landmarks were selected for each CBCT scan of the skull phantom. The slices were presented to six dentomaxillofacial radiologists, providing scores for various anatomical and diagnostic parameters. RESULTS A hyperbolic relationship was seen between CNRAIR and mAs. Similarly, a gradual reduction in clinical image quality was seen at lower mAs values; however, for several protocols, image quality remained acceptable for a moderate or large mAs reduction compared with the standard exposure setting, depending on the clinical application. The relationship between mAs, CNRAIR and observer scores was different for each CBCT device. Minimally acceptable values for mAs were between 9 and 70, depending on the criterion and clinical application. CONCLUSIONS Although noise increased at a lower mAs, clinical image quality often remained acceptable at exposure levels below the manufacturers recommended setting, for certain patient groups. Currently, it is not possible to determine minimally acceptable values for image quality that are applicable to multiple CBCT models.

Forensic oral imaging quality of hand-held dental X-ray devices: Comparison of two image receptors and two devices

Recently, different portable hand-held and battery-powered dental X-ray units have become available. Especially for forensic odontological purposes, they offer diverse advantages such as for use in disaster areas and crime-scene locations as also in autopsy rooms and mortuaries. For any application, the most important feature of these hand-held devices is the delivered image quality. The aim of this study is to evaluate the radiographic image quality acquired by two portable X-ray devices in combination with two types of image receptors and to compare the findings with the image quality of a standard intra-oral X-ray device. Eleven samples consisting of eight teeth, two dry skeletal specimens and one formalin-fixed mandible part were mounted on blocks for standardised (re)positioning. Radiological images were acquired with two hand-held (AnyRay 60 kVp, 0.02-4.00 mAs and NOMAD 60 kVp, 0.023-2.277 mAs) and one wall-mounted (MinRay 60/70 kVp 0.14-22.4 mAs) X-ray device combined with two image receptor systems (VistaScan phosphor storage plate (PSP) and SIGMA M CMOS Active Pixel technology sensor). The effect of X-ray source-to-object distance (SOD) was checked at 20 cm in conjunction with object to image receptor distances (OIDs) of 0.8 and 2.5 cm. For each parameter setup, the exposure times were run from low till high. An expert consent statement was achieved by agreement of four expert observers selecting the optimal images based on a developed four point quality rating system. Next, a selection of the images was assembled in a set of 198 observation screens and scored by seven observers. The observation screens were designed to compare observer scores, relations between devices, receptors and OIDs and images obtained from the different devices at equal exposure levels (mAs). All results were statistically analysed. Radiological image quality was significantly higher for phosphor plate compared with the CMOS digital receptor system (p<0.0001). Furthermore, a significantly superior image quality was obtained for OID=0.8 than for OID=2.5 (p=0.039). A significant difference in image quality between the three devices was also established (p=0.02). The present study demonstrated the feasibility of portable X-ray systems for forensic odontological applications based on rendering optimal image quality, provided an in vitro guideline of optimal parameter settings and offered a radiological image database usable in further research.

Image quality assessment and medical physics evaluation of different portable dental X-ray units

INTRODUCTION Recently developed portable dental X-ray units increase the mobility of the forensic odontologists and allow more efficient X-ray work in a disaster field, especially when used in combination with digital sensors. This type of machines might also have potential for application in remote areas, military and humanitarian missions, dental care of patients with mobility limitation, as well as imaging in operating rooms. OBJECTIVE To evaluate radiographic image quality acquired by three portable X-ray devices in combination with four image receptors and to evaluate their medical physics parameters. MATERIALS AND METHODS Images of five samples consisting of four teeth and one formalin-fixed mandible were acquired by one conventional wall-mounted X-ray unit, MinRay 60/70 kVp, used as a clinical standard, and three portable dental X-ray devices: AnyRay 60 kVp, Nomad 60 kVp and Rextar 70 kVp, in combination with a phosphor image plate (PSP), a CCD, or a CMOS sensor. Three observers evaluated images for standard image quality besides forensic diagnostic quality on a 4-point rating scale. Furthermore, all machines underwent tests for occupational as well as patient dosimetry. RESULTS Statistical analysis showed good quality imaging for all system, with the combination of Nomad and PSP yielding the best score. A significant difference in image quality between the combination of the four X-ray devices and four sensors was established (p<0.05). For patient safety, the exposure rate was determined and exit dose rates for MinRay at 60 kVp, MinRay at 70 kVp, AnyRay, Nomad and Rextar were 3.4 mGy/s, 4.5 mGy/s, 13.5 mGy/s, 3.8 mGy/s and 2.6 mGy/s respectively. The kVp of the AnyRay system was the most stable, with a ripple of 3.7%. Short-term variations in the tube output of all the devices were less than 10%. AnyRay presented higher estimated effective dose than other machines. Occupational dosimetry showed doses at the operators hand being lowest with protective shielding (Nomad: 0.1 microGy). It was also low while using remote control (distance>1m: Rextar <0.2 microGy, MinRay <0.1 microGy). CONCLUSIONS The present study demonstrated the feasibility of three portable X-ray systems to be used for specific indications, based on acceptable image quality and sufficient accuracy of the machines and following the standard guidelines for radiation hygiene.

Agreement between cone beam computed tomography images and panoramic radiographs for initial orthodontic evaluation

OBJECTIVE The aim of this study was to compare the agreement between cone beam computed tomography (CBCT) and panoramic radiographs for initial orthodontic evaluation. This study was not meant to test differences between imaging modalities or to indicate superiority of one technique. STUDY DESIGN Thirty-eight subjects with both panoramic and CBCT images were retrospectively collected. Eight observers answered 14 observational questions. The observation was repeated after 4 weeks. RESULTS CBCT images yielded better agreement between 2 observer groups (orthodontic residents and radiologists) and better inter- and intraobserver agreement. The agreement between panoramic radiographs and CBCT scans was moderate. CONCLUSIONS If CBCT is a priori present in a case with justified indications, it has the potential to provide valuable diagnostic information for initial orthodontic evaluation and extra information for treatment planning. The moderate agreement between panoramic and CBCT images may indicate that the nature and amount of information gained from both imaging sources is deviant.