Original Article 46

PHOTOGRAMMETRY AS A TOOL TO AID

ORTHODONTIC DIAGNOSIS AND TREATMENT
ASSESSMENT
Dr. Prasad Chitraa, , Dr. Ashwin Prakashb

ABSTRACT
Aim: To present simple photogrammetric techniques that can objectively evaluate standardized digital extra-
oral and intra-oral photographs for diagnostic and therapeutic purposes.
Materials and methods: 11 measurements (9 linear and 2 angular) from standardized lateral photographs
were compared with analogous measurements from standardized lateral cephalograms. The study was conducted
on 60 subjects (n=60, 41 females, 19 males) aged 18-25 years.8 photogrammetric techniques on standardized
photographs, linear and angular photogrammetric analysis on lateral photographs, linear photogrammetric
analysis on frontal and frontal smile photographs, photogrammetric analysis of occlusal cant, photogrammetric
smile analysis and tooth and intra-arch measurements on occlusal photographs are described.
Results: All 11 parameters that were analyzed showed strong correlation. The intraclass correlation coefficients
(ICC) and corresponding 95% confidence intervals (CI) of all parameters showed that the reliability of the
photographic technique was excellent.
Conclusions: Photogrammetry on standardized photographs used in daily orthodontic practice offers a simple,
cost effective solution without the hazard of radiation exposure. The 8 photogrammetric techniques described
here show that photogrammetry has multiple applications. However, there is a need to standardize
photogrammetric techniques, develop multiple photogrammetric analyses for different needs and obtain mean
values for parameters from different populations.
Keywords : Occlusal, photogrammetry, smile analysis, reliability

INTRODUCTION dimensional digital study models(Harrell et al, 2002).

Photography in dentistry has seen remarkable However, these techniques require the orthodontist to send
progress since 1839 when Alexander S Wolcott, a dentist the data to a third party image processing facility and
turned photographer, designed and patented the first involve high costs coupled with the need for dependence
camera from the Daguerre concept. (Galante, 2009; on advanced computer processing.
Humphrey, 1858) Today with continuing technological A simpler, cost effective solution would be application of
advancements in digital camera systems and computer photogrammetry on standardized photographs used in daily
software, photography has become an easily available and orthodontic practice. Photogrammetry may be defined as
cost effective diagnostic aid. (Sandler et al, 2012) ‘the art, science and technology of obtaining reliable
Photography has been given great importance as a information about physical objects through processes of
diagnostic aid by many pioneers in orthodontics, such as recording, measuring and interpreting photographic
Simon (Simon, 1924) and Graber (Graber, 1946); the latter images’. (Chadwick, 1992) The aim of the article is to
who included facial photography as an essential diagnostic present simple photogrammetric techniques to objectively
aid. evaluate standardized digital extra-oral (Claman et al, 1990)
The disadvantage of photographs and cephalograms is that and intra-oral photographs (Bengel, 2006) which could be
they provide two dimensional images of a three dimensional used in treatment planning and assessment.
structure. Some techniques exist which use computed Materials and Methods
tomography scans, magnetic resonance imaging, To determine whether photogrammetry could be used as a
destructive scans and laser scans to create three reliable tool to help in orthodontic diagnosis, 11
dimensional reconstruction of faces or create three measurements (9 linear and 2 angular) from standardized
lateral photographs were compared with analogous
measurements from standardized lateral cephalograms.
a-
MDS, M.OrthRCS(Edin), MDO RCPS(Glasg), (PhD) Professor and The study was conducted on 60 subjects (n=60, 41 females,
Head of Orthodontics and dentofacial orthopaedics, Army College of Dental
Sciences, 19 males) aged 18-25 years, with the mean age of 21 years
b-
Final Year Resident Dept. of Orthodontics & dentofacial orthopaedics and 6 months, SD 1.4.
Army College of Dental Sciences Inclusion Criteria
• All teeth till first molars were present.
 Prasad Chitra 47
Exclusion Criteria Radiographic Procedure
• No previous history of orthodontic or orthognathic Digital lateral skull radiographs were taken with a Cranex
treatment. D ® X- Mind Pano Ceph D+ (Acteon group, Satelec,
Soredex, Finland) cephalostat. Cephalometric radiographs
• No craniofacial trauma.
were obtained in Natural Head Position following the same
• No congenital anomalies. procedure as used for photographs. The modified protractor
• No neurologic disturbances. was used to achieve a similar angle obtained during
8 photogrammetric techniques on standardized photographic record taking(Fig.1c)
photographs, viz. linear and angular photogrammetric
24 landmarks were used in the study (Table 1)
analysis on lateral photograph, linear photogrammetric
analysis on frontal and afrontal smile photograph, Sl no Soft Tissue Landmark Ab* Radiographic landmark Ab*
photogrammetric analysis of occlusal cant,
1. Soft tissue Glabella G’ Glabella G
photogrammetric smile analysis and tooth and intra- arch 2. Soft Tissue Nasion N’ Nasion N
measurements on occlusal photographs, are presented, 3. Nasal Crown IND Nasal Crown IND
4. Pronasale Pn Pronasale Pn
which coud be used as effective diagnostic and treatment 5. Nasal Tip NT Nasal Tip NT
assessment follow up tools. 6. Nasale Medium Columella NM Nasale Medium Columella NM
Methodology for Assessing Reliabilty of the 7. Subnasale Sn Subnasale, Anterior nasal spine Sn,ANS
Photogrammetric Method 8. Soft Tissue subspinale A’ Subspinale A
Photographic Setup and Procedure 9. Labrale Superius (upper lip anterior) UL Labrale Superius (upper lip anterior) UL

A digital camera (Canon EOS 600D) mounted with a 10. Superior Labial Sulcus SLS Superior Labial Sulcus SLS
macro portrait lens (EF 105 mm f/2.8, 1:1 OS, Sigma) 11. Stomion superior Sto Stomion superior Sto
12. Stomion inferior Sti Stomion inferior Sti
was used to obtain photographic records. A distance of 5 13. Labrale inferius (Lower lip anterior) LL Labrale inferius (Lower lip anterior) LL
feet was maintained between the camera and the subject.
14. Inferior Labial sulcus ILS Inferior Labial sulcus ILS
The subject was made to face a mirror placed 120 cm away 15. Soft tissue submentale B’ Submentale B
to aid in obtaining Natural Head Posture (NHP). A metal 16. Soft tissue Pogonion Pog’ Pogonion Pog
17. Soft tissue Gnathion Gn’ Gnathion Gn
scale attached to a plumb line was secured just in front of 18. Soft tissue Menton Me’ Menton Me
the subject. A modified protractor (Moate, 2007) resting 19. Cervical point C Cervical point C
20. Soft tissue Orbitale Or’ Orbitale Or
on the tip of the nose and the soft tissue pogonion was 21. Tragion Trg’ Articulare, Condylion,Sella Ar,Co,Se
used to record NHP (Fig.1a) 22. Soft tissue Gonion Go’ Gonion Go
23. True Vertical line (upper point) TVLu True Vertical line (upper point) TVLu

24. True Vertical line (lower point) TVLi True Vertical line (lower point) TVLi

T bl 1 S ft ti l d k d th i di l di hi l d k d i th t d
Table 1. Soft tissue landmarks and their corresponding
analogous radiographic landmarks used in the study.
Ab* = Abbreviation

Computerized landmark identification and comparison

Fig.1 A. Modified protractor on tip of the nose and soft Digital photographic and radiographic records of 60
tissue pogonion to assess natural head position. B. Soft subjects were uploaded into Nemoceph 10.4.2 (Nemotec
tissue landmarks used in the study. Metal ruler with steel Dental Systems, Madrid, Spain) software program for
spokes separated at 50 mm placed in front of the subject Windows and were analysed using a customized analysis
indicates the true vertical (VER). C. Standardized digital configured in the software. The soft tissue and analogous
lateral cephalograms of the same patient with the metal hard tissue landmarks were digitally identified by a single
scale in place. Metal scale is used to calibrate both images. examiner (Fig.2) The 2 spokes of the ruler separated by a
distance of 50 mm were used as the reference distance for
both photographic and cephalometric records.
Orbitale, Menton, Gonion and Tragus points were palpated Statistical Analysis
directly on subjects and marked with a micro metallic ball Data was statistically analysed using the Statistical Package
for clear representation in the photographs(Fig.1b). for Social Sciences, version 23 (SPSS Inc, Chicago, Ill).
Subsequently, right lateral profile photographic views were Cephalometric measurements were compared with
taken for all subjects in maximum intercuspation with lips analogous photographic measurements to assess Pearson
at rest. correlation coefficients. Intra class correlation coefficient
was calculated for photographic (independent variable)

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 Prasad Chitra 48
Linear photogrammetric analysis on frontal and frontal
smile photographs
For frontal photogrammetric analysis, a patient with
unilateral scissor bite involving 44 – 47 was selected. The
patient was instructed to hold a modified fox plane with a
90 mm metal scale trimmed and bonded on its surface for
the purpose of calibration. The frontal photograph obtained
was uploaded into Photoscape software and horizontal
planes (90 mm calibration, mental width, bigonial width,
Fig.2 Landmarks are digitally identified for lateral bizygomatic width, bitemporal width, interpupillary
cephalograms. A. and photograph B. using Nemoceph distance, line connecting two upper cuspids, alar base
10.4.2 software with control points shown. width) were marked. The facial midline and vertical lines
on both side of face connecting outer canthus, inner
measurements to determine the reliability of canthus, ala of nose, and lip commissures were drawn. The
photogrammetric evaluation of soft tissues. image with marked planes was uploaded in Nemotec
software for linear photogrammetric measurements (Fig
4a, 4b).
Occlusal cant analysis
To assess the presence of occlusal cant, the patient was
instructed to place a wooden tongue blade inter-occlusally
as posterior as possible and bite on it. The modified fox
plane as well as the vertical ruler can be used for calibration
purposes. Similar planes as constructed in frontal
photographs can be used in this analysis. The vertical
Fig.3 Landmarks are digitally identified for lateral distance from pupil and outer ala of nose are measured on
cephalograms. A. and photograph B. using Nemoceph both sides to determine occlusal cant (Fig 5a).
10.4.2 software with control points shown.

Methodology for Extra- Oral Photogrammetry

techniques
Linear and angular analysis on lateral photographs
Landmarks which were recorded in the study (Table1) were
digitally identified in Photoscape®software (Copyright (C)
2001-2017 MOOII TECH). The metal scale can be taken
as the True vertical and horizontal planes perpendicular to
True Vertical were drawn from Sn and Me. A straight line
connecting the nasal tip and soft tissue pogonion is
constructed. The image was then uploaded in Nemotec
software for linear photogrammetric measurements (Fig
3a). The angular analysis can be performed similarly in
the Nemotec software from customized cephalometric
analysis (Fig 3b)
Fig. 5 The modified fox plane with metal spokes separated
by 90 mm can be used for calibration purposes. The linear
distance from pupil and outer ala of nose to base of tongue
blade is measured on both sides to metrically determine
the occlusal cant.

Smile analysis
For the smile analysis a magnification ratio of 1:2 was
maintained. The patient was asked to hold a metal ruler
beneath the lower lips and instructed to produce a full
Fig.4 A,B. Frontal photograph and Frontal smile natural and relaxed smile. Vertical lines corresponding
photograph marked with vertical and horizontal planes in to the dental midline and demarcating the buccal smile
Photoscape. C,D. Photogrammetric analysis performed on corridor were drawn using Photoscape® software (Fig 6a).
both photographs in Nemotec software.

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 Prasad Chitra 49

Sl no Measurement Intraclass 95 % confidence interval

correlation Upper bound Lower bound
1. Nasomental Angle .977 .991 .942
2. NB LsPog' Angle .988 .995 .969
3. UL:En-Pog' .986 .995 .965
4. Lower lip length .991 .996 .977
5. Middle 1/3 height .985 .994 .962
Fig. 6 A. A metal scale is used to calibrate the picture. 6. LL:En-Pog' .974 .990 .934
Vetrical lines representing the buccal corridor space and 7. Lip to lip .980 .992 .949
the dental midline are drawn in Photoscape software. B. 8. Sts to Me’ .988 .995 .970
The measurements obtained in the smile analysis are
shown.
9. Protrusión Labial .974 .990 .934
Methodology for Intra- Oral Occlusal 10. Sn to Me’ .985 .994 .962
Photogrammetry 11. Nsn (N' to Sn) .973 .989 .932
Photographic Setup and Procedure
In this technique, a modified intra oral combination mirror Table 3: Intraclass correlation and 95% confidence
(Prakash et al, 2016) was used. A 35 mm trimmed metal intervals of the 11 parameters.
scale bonded on the front surface of an occlusal cheek
retractor was used for calibration purposes. The image The intraclass correlation coefficients (ICC) and
was subsequently uploaded into Nemotec software to corresponding 95% confidence intervals (CI) of all 11
photogrammetrically measure mesiodistal width of all teeth parameters showed that the reliability of the photographic
up to first molars and intra arch widths (Fig 7a, 7b) technique was excellent. All the parameters showed ICCs
> .973. Lower lip length showed the highest ICC value
with .991.
RESULTS Linear and angular analysis on lateral photographs
Analysis of 11 parameters that were analyzed showed The values obtained for the 9 linear parameters and 2
strong correlation (Table2). angular parameters for 60 subjects are shown in Table 4.

Sl no Measurement Mean SD
Sn Nt A. Measurement Ceph point Photo point (r)* I 1. Nasomental Angle 124.50 4.52
1. Nma Nasomental a IND N’NTPog’ IND N’NTPog’ .823 S 2. NB LsPog' Angle 14.97 3.75
2. Nbp* NB ^ LsPog' NB-Ls-Pog’ N’B’-Ls-Pog’ .787 S 3. UL:En-Pog' -2.88 2.12
4. Lower lip length 41.80 5.75
3. Tfh Total facial height TVLu TVLi- N’ Me’ TVLu TVLi- N’ Me’ .920 S 5. Middle 1/3 height 73.66 9.61
4. Nsn N' to Sn TVLu TVLi- N’ Sn TVLu TVLi- N’ Sn .883 S 6. LL:En-Pog' -2.02 2.31
5. Snme Sn to Me´(LTH) TVLu TVLi – Sn Me’ TVLu TVLi – Sn Me’ .852 S 7. Lip to lip -2.71 1.70
8. Sts to Me’ 45.36 7.13
6. Mth3 Middle Third TVLu TVLi – G’ Sn TVLu TVLi – G’ Sn .850 S 9. Protrusión Labial -2.02 2.31
7. Llsme Lower lip length TVLu TVLi- Sti Me’ TVLu TVLi- Sti Me’ .835 S 10. Sn to Me’ 64.82 9.07
8. Stsme Sts to Me´ (D) TVLu TVLi- Sts Me’ TVLu TVLi- Sts Me’ .800 S 11. Nsn (N' to Sn) 48.31 6.34
9. Ltl Lip to lip TVLu TVLi- UL LL TVLu TVLi- UL LL .754 S Table 4: The mean values for the 9 linear and 2 angular
parameters. (n = 60)
10 Uep UL:En-Pog' NT-Pog’-UL NT-Pog’-UL .815 S The average value of Nasomental angle (N-Prn/ N-Pog)
11 Plab Protrusión Labial NT Pog’ – LL NT Pog’ – LL .802 S obtained in the study is 124.50 ± 4.5, which is similar to
the average value of nasomental angle in the North Indian
population obtained by Reddy et al (2011). In the current
Table 2: 11 parameters that showed strong correlation.
1-2 (angular measurements), 4-9 vertical measurements
study the nasal height (N’-Sn) value of 48.312 ± 6.3479,
and 10-11 are horizontal measurements. was similar to the value obtained by Fernandez-Riveiro et
al (2002) (N-Sn: males 52.5 ± 4 mm and females 49.8 ± 4
mm). The interlabial gap at rest (mean value 0.38 mm)
Lateral photographs of 20 subjects were randomly selected
was similar to the value obtained by Fernandez-Riveiro et
and analyzed twice. The intraclass correlation coefficients
al (2002). The upper lip length obtained in the study (21.5
(ICC) and corresponding 95% confidence intervals (CI)
± 6.7) was more than the value obtained by Park and
were estimated to measure the reliability of the repeated
Burstone (18 ± 2 mm).
tracings.(Table 3).

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 Prasad Chitra 50
Linear photogrammetric analysis on frontal and frontal Occlusal photogrammetric analysis
smile photographs Nemotec software can be used to measure the mesiodistal
The photogrammetric measurements obtained from frontal widths of all teeth up to the first molar and the inter
smile and frontal photographs are shown in Table 5. (fig premolar width, inter canine width and inter molar width
4c, 4d) (Fig. 7c).
Parameter Value Parameter Value DISCUSSION
(Frontal smile) (mm) (Frontal) (mm) A proper diagnosis undoubtedly forms the cornerstone in
Bimental width 53.61 N’-Sn 43.90 constituting sound orthodontic treatment. It is pertinent
Bigonial width 92.40 Sn-Me’ 66.56 that the orthodontist follows a thorough and proper
Bizygomatic width 124.20 Dental 1.53 diagnostic protocol to obtain consistent and predictable
Midline shift results. With advances in technology and increased use of
Bitemporal width 93.94 Inter 46.13 computers in the daily orthodontic practice, newer tools
commissural are becoming popular to help us intelligently analyze and
width interpret diagnostic data. Photogrammetry is one such tool
Inter pupillary distance 59.30 ULS-LLS 25.54 that can be easily used and has a relatively low learning
Inner canthal distance 28.36 Sti-Sto 6.81 curve.
Outer canthal distance 88.72 Sn- ULS 10.91 The present study shows that photogrammetry is a reliable
Alar base width 37.98 N’-Me’ 110.46 tool which could be used as an adjunct to other diagnostic
Gingival exposure 7.01 aids like cephalometric analysis. Jorgensen (1991) in his
study to quantify facial changes that occur between 4 and
Table 5: The values obtained for the linear parameters 13 years of age concluded that, in general, landmark
measured in frontal smile and frontal photographs. identification on photographs was reproducible.
Additionally, the frontal photograph can be used to Goodlin (2005, 2011) and Calamia et. al ( 2007) have
determine facial asymmetry by measuring the bimental, discussed the use of photography assisted diagnosis and
bigonial,bizygomatic, inter-pupillary and alar base width treatment planning, with the latter designing a smile
on right and left sides as divided by the facial midline. evaluation form which is used in New York University
The examined patient showed increased width on the right College of Dentistry (NYUCD). Stereophotogrammetry has
side in all widths [inter – pupillary .42 mm, bizygomatic been used to analyze the contours of surgically corrected
.49mm, alar base 1.43 mm, bigonial .16mm except faces by Berkowitz (1971) and Burke (1971) to monitor
bimental width which decreased by .54 mm] (Fig 4d). growth of facial soft tissues.
Occlusal cant analysis Lateral and frontal photogrammetric analysis
The occlusal cant analysis shows that the patient described Epker (1992) took his records in NHP, using the true
(Fig. 5b) has an increased occlusal cant towards the right vertical (TV) as the reference line on which he defined
side as evinced by the increased vertical distance from inter proportional measures as the following: the upper lip (Sn-
pupillary (4.63 mm) and alar base (1.99) width to the base Sto) was 30% of the inferior third of the face (Sn-Gn), the
of the tongue blade. inferior lip (Sto-Sm) was 28% of the inferior third of the
Smile analysis face, the height of the chin was 42% of the inferior third
Smile analysis can help to objectively quantify buccal and nasal depth (Sn-Prn) was 40% of the nasal length (N-
corridor space, distance between the vermillion border of Sn). Arnett and Bergman (1993) described an analysis of
upper and lower lip and upper and lower stomion the soft tissue facial profile on photographic records in
respectively, as well as ratios of mesiodistal width and NHP. Their analyses of the symmetry, both vertical and
height of the teeth to digitally evaluate patients smile (Fig. horizontal, contour of the smile line, facial middle lines,
6b). and facial contour were important.
Riveiro et al. in 2002, digitally analyzed the soft tissue
facial profiles of a European
white population of young adults by means of linear
measurements made on
standardized photographic records taken in natural head
position.
Smile analysis
Ackerman and Ackerman in 2002, performed a smile
analysis in a program called SmileMesh, which measured
Fig. 7 A. Single combination mirror used in the procuring 15 attributes of the smile. More recently, Sodagar et al. in
occlusal photographs. B. A 35 mm metal scale is trimmed 2010 designed a software for smile analysis and McLaren
and bonded on both sides of the cheek retractor. C. A et al in 2013, have described the various applications of
mandibular occlusal photograph showing scale used for digital dentistry with the help of Photoshop® software.
calibration and the mesiodistal width and intra arch widths
measured in Nemotec software.

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 Prasad Chitra 51
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March 2017 Vol-1 Issue - II Journal of Contemporary Orthodontics