UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3726
1
Braz Dent Sci 2023 Jan/Mar;26 (1): e3726
A radiation free alternative to CBCT volumetric rendering for soft
tissue evaluation
Um método alternativo à TCFC sem radiação ionizante para a avaliação de tecidos moles da face
Giovanna PERROTTI
1
, Rodolfo REDA
2,3
, Ornella ROSSI
1
, Isabella D’APOLITO
4
,
Tiziano TESTORI
1,5,6,7
, Luca TESTARELLI
2,3
1 - Lake Como Institute, Como, Italia.
2 - Sapienza Università di Roma, Dipartimento di Scienze Odontosomatologiche e Maxillo Facciali, Roma, Italia.
3 - Saveetha Institute of Medical and Technical Sciences, Department of Prosthodontics and Implantology, Saveetha Dental College and
Hospitals. Chennai, India.
4 - Università Cattolica del Sacro Cuore, School of Dentistry. Rome, Italy.
5 - IRCCS Istituto Ortopedico Galeazzi, Clinica Odontoiatrica, Sezione di Implantologia e Riabilitazione Orale. Milano, Italia.
6 - Università degli Studi di Milano, Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche. Milano, Italia.
7 - University of Michigan, School of Dentistry, Department of Periodontics and Oral Medicine. Ann Arbor, MI, USA.
How to cite: Perrotti G, Reda R, Rossi O, D’Apolito I , Testori T, Testarelli L. A radiation free alternative to CBCT volumetric rendering
for soft tissue evaluation. Braz Dent Sci. 2023;26(1):e3726. https://doi.org/10.4322/bds.2023.e3726
ABSTRACT
Objective: The aim of the present study is to evaluate whether a “radiation free” method using 3D facial scan can
replace Cone Beam Computed Tomography (CBCT) volumetric rendering of soft tissue of the patient to assess
maxillofacial surgery outcomes and compare the reference points and angular measurements of patient facial soft
tissue. Material and Methods: Facial soft tissue scan of the patient’s face, before and after orthognathic surgery and
a CBCT of the skull for volumetric rendering of soft tissues were carried out. The 3D acquisitions were processed
using Planmeca ProMax 3D ProFace® software (Planmeca USA, Inc.; Roselle, Illinois, USA). The participant were
positioned in a natural position during the skull scannering. Three sagittal angular measurements were performed
(Tr-NA, Tr-N-Pg, Ss-N-Pg) and two verticals (Go-N-Me, Tr-Or-Pg) on facial soft tissue scan and on the patient’s
3D soft tissue CBCT volumetric rendering. Results: A certain correspondence has been demonstrated between
the measurements obtained on the Proface and those on the CBCT. Conclusion: A radiation free method was
to be considered an important diagnostic tool that works in conditions of not subjecting the patient to harmful
ionizing radiation and it was therefore particularly suitable for growing subjects. The soft tissue analysis based
on the realistic facial scan has shown sufcient reliability and reproducibility even if further studies are needed
to conrm the research result.
Keywords
CBCT; Ionizing radiation; Soft tissue; Orthodontics; Diagnosis.
RESUMO
Objetivo:Avaliar se um método “livre de radiação” usando escaneamento facial 3D pode substituir a renderização
volumétrica da tomograa computadorizada de feixe cônico (TCFC) dos tecidos moles do paciente para analisar
os resultados da cirurgia maxilofacial e comparar os pontos de referência e medições angulares am de avaliar a
correspondência entre as duas metodologias. Material e Métodos: Foi realizado o escaneamento dos tecidos moles
faciais do paciente, antes e depois da cirurgia ortognática e uma tomograa computadorizada de feixe cônico do
crânio para renderização volumétrica dos tecidos moles. As aquisições 3D foram processadas usando o software
Planmeca ProMax 3D ProFace® (Planmeca USA, Inc.; Roselle, Illinois, USA). O participante foi posicionado em
posição natural durante o escaneamento do crânio. Três medições angulares sagitais foram realizadas (Tr-NA,
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3726
Perrotti G et al.
A radiation free alternativ e to CBCT v olumetric r endering for soft tissue e v aluation
Perrotti G et al.
A radiation free alternative to CBCT volumetric rendering for
soft tissue evaluation
INTRODUCTION
Originally, the orthodontic diagnosis was
conducted through the evaluation of the hard
tissues, skeleton and teeth, on the basis of the
lateral teleradiograph and the dental cast [1].
Starting with Tweed, all the major 2D
cephalometries presented mainly one aesthetic
parameter of soft tissue which considers the
relationship between nose, lips and chin but always
on a bidimensional sagittal prospective [2,3].
In the late 1990s Arnett and co. strongly
criticized cephalometric analyzes that focused the
treatment plan mainly on hard tissue parameters.
Arnett advocated what interests the patient is not
the ideal skeletal and dental ratio, but a series
of aesthetic-morphometric parameters based on
the quality of the soft tissues, which however
could mask serious conditions of malocclusion
or skeletal discrepancy [4-6].
The increasing desire in the last few years
to improve patients’ facial appearance had
placed aesthetics as the rst treatment objective
for orthodontists and maxillo-facial surgeons
who had as obligation the maintenance or
improvement of facial aesthetic parameters [7].
Therefore, the assessment of facial
morphology has found a greater interest among
clinicians and the precise and detailed evaluation
of soft tissues has become more and more
relevant [8].
Furthermore, it has been demonstrated that
patients as well as their friends and relatives
evaluate the result of the orthodontic and
orthognathic treatment on the perceived changes
in the face [9].
This great interest in non-invasive methods
has led to the development of new imaging
tools that can improve the role of soft tissue in
diagnosis [4,5].
A full assessment of the three-dimensional
shape, size and proportions of the facial soft
tissues must therefore be considered as a decisive
step in the orthodontic diagnosis.
The possibility of studying facial features
using non-invasive 3D radiographic systems,
such as laser surface scanning, multi-image
photogrammetry, stereo-photogrammetry or by
the recent 3D facial photography technique had
become concrete. Furthermore, facial surface
could be appreciated and obtained through the
3D rendering of soft tissues from the face starting
from the Digital Imaging and COmmunications in
Medicine (DICOM) les of a skull scan.
These recent methods offered several
benefits, including speed of data collection,
data retention and management, accuracy and
reliability [6-10].
It is necessary to underline how important
a reproducible head position is during images
acquisition. However, the difculty encountered
in reliably performing facial acquisition was likely
responsible for the secondary role of soft tissue
analysis in supportive diagnosis compared to
skeletal analysis [10,11].
However, there were also complications
related to the appropriate use of equipment and
software as well as the absence of reliable norm
values for 3D measurements of facial soft tissues,
which requires further study.
Several analyzes have been proposed in the
past for the facial soft tissue evaluation. Most
include photographic images from a lateral point
of view [7,12]. Some authors also proposed
the evaluation of soft tissues using frontal
images [10,11]. However, 3d facial scan allowed
to better appreciate soft tissues from every
Tr-N-Pg, Ss-N-Pg) e duas verticais (Go-N-Me, Tr-Or-Pg) nas imagens de scaneamento e nas imagens do tecido
mole facial da reconstrução tridimensional da TCFC. Resultados: Uma certa correspondência foi demonstrada
entre as medidas obtidas no Proface® e aquelas na TCFC. Conclusão: Um método livre de radiação deve ser
considerado uma importante ferramenta de diagnóstico que funciona em condições de não submeter o paciente
a radiação ionizante nociva e, portanto, é particularmente adequado para indivíduos em crescimento. A análise
de tecidos moles com base na varredura facial realista mostrou conabilidade e reprodutibilidade, porém mais
estudos são necessários para conrmar o resultado da pesquisa.
PALAVRAS-CHAVE
Ortodontia; Radiação não ionizante; Tecidos moles; Tomograa computadorizada de feixe cônico; Diagnóstico.
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3726
Perrotti G et al.
A radiation free alternativ e to CBCT v olumetric r endering for soft tissue e v aluation
Perrotti G et al.
A radiation free alternative to CBCT volumetric rendering for
soft tissue evaluation
perspective, identify reference points and carrying
out measurements in three dimensions [13,14],
make a precise analysis of facial soft tissues and
collect patient data and information over time.
To the authors’ knowledge, to date, no
studies comparing soft tissue changes between
3D facial scan images and that obtain from a
CBCT 3D rendering have been reported. The aim
of the present study is to compare the values
obtained from the facial scan with that obtained
from a 3D rendering obtained from a CBCT of
the same patient in order understand if they are
overlapping.
MATERIALS AND METHODS
A clinical case of a patient with severe facial
asymmetry and undergoing combine orthodontic-
surgical treatment is shown.
As protocol for surgical cases, a CBCT
with Planmeca Viso® G7 (Planmeca USA,
Inc.; Roselle, Illinois, USA) with hard and soft
tissue of the patient is taken and, furthermore,
a 3D soft tissue facial scan of the patient with
Planmeca ProMax 3D ProFace® (Planmeca USA,
Inc.; Roselle, Illinois, USA), before and after
orthognatic surgery (Figure 1A-B).
Ethical approval has not been required
for this type of study. The CBCT and the facial
scan of the patient have been required by the
maxillofacial surgeon in order to plan the surgery.
The patient, adequately informed of the risks
and benets of radiographic investigations, has
deliberately signed the consent to perform the
CBCT and the facial scan and to use the data for
the purposes of scientic research.
The facial soft tissue scan was made with
Planmeca ProMax 3D ProFace®, which produces
a realistic 3D image of the face (Figure 2A-B).
The photographs were acquired using the
ProFace option, which does not require radiation.
This system relies on lasers able to scan
facial geometry and some digital cameras, which
capture texture and color. The sensor is composed
of two laser lights, two digital cameras and two
light-emitting diodes.
The spatial accuracy of this device is 0.03mm
(as reported by the manufacturer). During the
acquisition of the image, the patient’s head lay in
the natural position, the face presented a neutral
expression, the jaw was in a resting position
as well as the lips in the absence of excessive
muscular effort.
Taking up the scientic work carried out
by Zecca et al. [15], the same reference points
were used for the cephalometric analysis of soft
tissues but only some angular measurements
used by them. Specically, three sagittal angular
measurements (Tr-N-A, Tr-N-Pg, Ss-N-Pg)
and two vertical ones (Go-N-Me, Tr-Or-Pg)
were selected to obtain a good anatomical
correspondence between hard and soft tissue.
These measurements were taken both on
the facial soft tissue scan of the face thanks to
Figure 1 - A: Rendering 3D Soft Tissue Pre-surgery; B: Rendering 3D
Post Surgery
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3726
Perrotti G et al.
A radiation free alternativ e to CBCT v olumetric r endering for soft tissue e v aluation
Perrotti G et al.
A radiation free alternative to CBCT volumetric rendering for
soft tissue evaluation
Romexis software which allow to take linear and
angular measurements and on the CBCT soft
tissues volume rendering with SimPlant O&O by
Materialise Dental. Version: 3.0.
RESULTS
The aim of the present study is to analyze
whether the measurements made on the 3D face
foto obtained with Proface are correlated with
patient’s CBCT soft tissues 3D rendering, before
and after surgical treatment. The sequence of the
same measurements has been taken.
Figure 2A show the measurements made
on the Planmeca ProMax 3D ProFace® software
and on the patient’s pre-treatment 3D soft tissues
rendering respectively.
Figure 2B show the measurements made
on the Planmeca ProMax 3D ProFace® software
and on the patient’s post -surgery 3D soft tissues
rendering.
The measurements have been reported in
Table I.
Figure 1A-B show the measurement of soft
tissue on CBCT volumetric rendering before and
after patient’s surgery.
As can be seen from the results obtained,
a correspondence between the measurements
performed on the Planmeca ProMax 3D ProFace®
software and those on the patient’s CBCT
soft tissues rendering, in accordance with the
orthodontic-surgical treatment performed was
obtained.
DISCUSSION
Thanks to the advent of 3D facial scan, it
is possible to better appreciate soft tissues from
every perspective and in three dimensions,
identifying reference points and carrying out
angular and linear measurements [13,14]. It is
so possible to do a precise analysis of facial soft
tissues and collect data and information of the
patient over time.
The role of facial soft tissue assessment is
becoming increasingly important in orthodontic
diagnosis and treatment planning, especially in
patients undergoing maxillo-facial surgery [16].
The treatment effects on soft tissue prole
when managing the underling dental and
skeletal changes to estimate facial and occlusal
improvements must be kept under control [15,16].
Table I - Proface and Soft-Tissue CBCT angular measurements, pre- and post-surgery, of the followers parameters: Tr-N-Subnasal, Tr-N-Pg,
Sspinal-N-Pg, Go-N-Me, Tr-Or-PG (Tr=trichion), N= Nasion, Sn=subnasal, Pg= Pogonion, Sp=Subspinale, Go= Gonio,n Me=Menton, Or= Orbitale)
Proface and Soft-Tissue CBCT Rendering 3D
Measurements
Proface CBCT Soft Tissue
Pre-Surgery (°) Post-Surgery (°) Pre-Surgery (°) Post-Surgery (°)
Tr-N-Sn 76.20 75.20 79.92 73.27
Tr-N-Pg 70.00 66.80 73.89 51.21
Sp-N-Pg 2.50 4.30 4.30 2.55
Go-N-Me 37.90 38.10 44.01 37.30
Tr-Or-Pg 107.40 109.40 111.87 112.71
Figure 2 - A: Proface Pre Surgery; B: Proface Post Surgery
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Perrotti G et al.
A radiation free alternativ e to CBCT v olumetric r endering for soft tissue e v aluation
Perrotti G et al.
A radiation free alternative to CBCT volumetric rendering for
soft tissue evaluation
A truthful evaluation of the treatment
outcome is made possible through out a radiation
free method based on 3D Facial Scan.
The analysis of 3D Facial Scan can be
objectified through linear and angular
measurements performed on the scan. From our
results, no signicant differences between 3D
facial scan of the patient and CBCT soft tissues
volumetric rendering has been seen.
This could suggest an alternative non-
radiogenic method, especially useful in those
situations where radiation should be further
reduced (children and patients with radiation
correlated risk) [17].
When possible, the clinician have to reduce
the radiogenic load in patients and efciently
use other tools available to elaborate a correct
diagnosis. 3D facial scan is one of these tools
that should be correlated and implemented with
further measurement and comparison system.
The outcomes of a surgical and orthognatic
treatment should be seen more on the aesthetic
result of soft tissues that reect the new positioning
of the bones.
The 3D Facial Scan method offers several
advantages over conventional (non-3D)
photography, considering the possibility of
obtaining 3D images and reliability to perform
facial analysis [8].
Several techniques for obtaining digital images
have been proposed over the years. The possibility
of adequately reproducing tissue landmarks
and therefore making these measurements
reproducible is extremely important. The use
of laser scans and stereophotogrammetry (both
non-invasive and non-ionizing) have gained most
favor in the orthodontic literature [12].
Laser scanning is a non-invasive 3D facial
images acquisition method and has been
successfully applied in studies of treatment
outcome and relapse [12].
Facial soft tissue analysis, taking into account
skeletal morphology or occlusal orthodontic
treatments, is assuming an increasingly important
role in orthodontic diagnosis and treatment
planning. Therefore, having the ability to diagnose
and monitor soft tissue analysis over time allows
us to have a source of diagnostic information and
treatment outcome evaluation [15].
The growing interest in non-invasive
diagnostic examinations by the clinicians and the
growing request of aesthetic improvement by the
laypersons are the reason why attention to soft
tissue has increased in recent years. Nevertheless,
one of the difficulties of planning soft tissue
analysis is perhaps dictated by the fact that
great importance has been given to hard tissue
analysis for orthodontic purposes in the recent
past [10,11]. The limits of facial examination
include costs for the machines, difficulty in
handing, technique-sensitive difculties when
capturing the deeper tissues, and rendering [18].
A limitation of facial scanning and 3D rendering
of soft tissues from CBCT is the difficulty to
effectively detect the surface of a patient’s face
without there being image distortion. Even
the slightest movement by the patient or the
compression of some facial areas (chin, forehead,
ears, cheeks) greatly alters the final result.
To date, there is no an effective system to block
the patient’s head without compressing the soft
structures of the face. Despite limitations in
scan quality and software operation, 3D facial
scanners are rapid and non-invasive tools that
can be utilized in multiple facets of facial and
dental care [19].
Non-invasive diagnostic examination could
be of great importance in orthodontic diagnosis
and for orthodontic treatment follow-up, making
further radiological exams prescribed only when
needed [15]. Furthermore, this can also allow for
a more adequate evaluation of the soft tissues,
allowing the noble structures adjacent to the sites
to be treated to be isolated and protected in the
treatment plans [20,21].
Even today, the most described follow-up
exam is a lateral cephalometric radiograph,
although this only allows for the verication of a
linear, vertical, and anteroposterior progression
of facial change, always and exclusively in two-
dimensions. For the type of acquisition of the
lateral projection image, no depth or specific
orientation of landmarks can be revealed.
The aforementioned limits have been overcome
in recent years, considering radiation-free 3D
imaging or with reduced exposure to ionizing
radiation for the analysis of hard and soft
tissues [22,23].
With these acquisitions it is possible to
monitor the 3D changes of the facial proles.
The possibility of working on data in 3D rather
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Perrotti G et al.
A radiation free alternativ e to CBCT v olumetric r endering for soft tissue e v aluation
Perrotti G et al.
A radiation free alternative to CBCT volumetric rendering for
soft tissue evaluation
than 2D allows to obtain even more information,
as also underlined in other recently published
studies [24,25].
Therefore, the previous considerations
lead us to state that the best way to describe
the facial changes that occur after orthognathic
treatment requires the use of an imaging
system that captures the facial anatomy in its
complexity [26-28].
CONCLUSIONS
The present soft tissue analysis proposal
based on 3D facial scans has shown good reliability
and reproducibility although further studies are
needed to conrm the search result. Radiation
free methods to perform cephalometric tracings
on soft tissues should be able to become an
increasingly predictable method in order to reduce
the radiogenic load to which the orthodontic
patient is subjected. The use of 3D images without
the support of a numerical evaluation scheme and
standard values for comparison and diagnosis
make these devices less widespread while for
objective necessity, conventional radiological
systems or CBCT continue to be used even in
non-elective situations.
The combination of intraoral scans and a
radiation free cephalometry may represent the
future of the diagnostic approach in orthodontics.
The future of digital scanning is expected to
involve wide availability of scanners at lower
costs with high quality and accuracy for various
dental and medical applications.
Author’s Contributions
GP: Conceptualization, resources,
writing—original draft preparation. RR:
Validation, writing—review and editing. OR:
Conceptualization, software, investigation,
data curation. IA: Methodology, formal
analysis, writing—original draft preparation.
TT: Validation, writing—review and editing,
supervision. LT: Validation, visualization.
Conict of Interest
The authors have no proprietary, nancial,
or other personal interest of any nature or kind
in any product, service, and/or company that is
presented in this article.
Funding
This research received no external funding.
Regulatory Statement
Ethical approval has not been required for
this type of study. The CBCT and the facial scan of
the patient has been required by the maxillofacial
surgeon in order to plan the surgery. The patient,
adequately informed of the risks and benets
of radiographic investigations, has deliberately
signed the consent to perform the CBCT and the
facial scan and to use the data for the purposes
of scientic research.
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3726
A radiation free alternative to CBCT volumetric rendering for
soft tissue evaluation
Perrotti G et al.
A radiation free alternativ e to CBCT v olumetric r endering for soft tissue e v aluation
Perrotti G et al.
A radiation free alternative to CBCT volumetric rendering for
soft tissue evaluation
Date submitted: 2022 Dec 05
Accepted submission: 2022 Dec 05
(Corresponding address)
Rodolfo Reda
Sapienza Università di Roma, Dipartimento di Scienze Odontostomatologiche e
Maxillo Facciali, Roma, Italia.
Email: rodolfo.reda@uniroma1.it
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