Evaluating the accuracy of facial models

obtained from volume wrapping: 2D

images on CBCT versus 3D on CBCT
Soghyia Almulla, Pratik Premjani, Nikhilesh R. Vaid, Dhaval F. Fadia, and
Donald J. Ferguson

Purpose: To test for difference in accuracy of 3D facial integument measure-

ments of three indirect facial measurement techniques compared to measur-
ing integument facial features directly. Materials & Methods: Four
measurement methods were used to measure 25 patients (15 females and
10 males): 1) direct anthropometric facial (direct), 2) volume wrapping 2D
images on CBCT (2D wrap), 3) volume wrapping 3D facial scan using Artec
Eva on CBCT (3D wrap), and 4) direct 3D face scan (3D scan). Statistical differ-
ences were determined at the 99% probability level and clinical significance
was >0.5 mm. Results: Direct technique measurements were significantly
smaller than the other three techniques in 7 of 26 (26.8%) measurements.
Differences between 3 of 7 measurements exceeded 0.5 mm and were
deemed clinically significant, i.e. upper face height (N-Sto), lower face height
(Sn-Gn) and nasal tip projection (Sn-Prn). The remaining 23 of 26 direct
measurements could be substituted by 2D wrap, 3D wrap or 3D scan mea-
surement techniques. Compared to the direct technique, 2D volume wrap on
CBCT values were closer than the values obtained from the 3D volume wrap
and 3D CBCT techniques. Conclusions: Compared to the “gold standard”
direct measurements, the other three techniques in 23 of 26 face and ear
measurements (88.5%) could be substituted one for the other, and demon-
strated a fairly high level of precision. (Semin Orthod 2018; 24:443–450) ©
2018 Elsevier Inc. All rights reserved.

Introduction photographs increase the likelihood of clinical

inaccuracies, since information is contained
raditionally, facial data of patients are
T recorded using pre and post treatment pho-
tographs. Although this method represents n
within a single plane of space. Three-dimen-
sional (3D) imaging is the gold standard for
facial imaging and measurements.1,2 3D photos
easy and intuitive way to assess treatment, the
and scans are effective in locating the source and
procedure does not provide sufficient diagnostic
magnitude of deformity. They can be manipu-
information and is influenced by many factors,
lated in any spatial plane thus providing valuable
including the distance and angle at which the
information to the orthodontist without the
photograph is taken. Two-dimensional (2D)
need for patient recall or the time constraints of
clinical examination. Contemporary treatment
European University College, DHCC, Dubai, United Arab Emi- concepts suggest that clinicians start treatment
rates; Advanced Program, European University College, DHCC,
Dubai, United Arab Emirates; European University College, DHCC,
planning from the external profile.3 A 3D “vir-
Dubai, United Arab Emirates; 3D Future Technologies, Mumbai, tual patient” for planning can easily be created
India; European University College, Dubai Healthcare City, Ibn Sina by the 3D records; hence, 3D record taking is
Building, Block D, 3rd Floor, Office 302, PO Box 53382, Dubai, currently gaining popularity as an integral fea-
United Arab Emirates. ture of the diagnostic process. Three dimen-
Corresponding author. E-mail: fergusonloud@gmail.com
sional records also aid in educating the patient
© 2018 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
about the predicted impacts of different treat-
https://doi.org/10.1053/j.sodo.2018.10.008 ment modalities.

Seminars in Orthodontics, Vol 24, No 4, 2018: pp 443 450 443

444 Almulla et al
One method used to obtain a 3D facial model
is to register the skin-surface images acquired by
stereophotogrammetry and layer them over a
CBCT image using portable stereometric cam-
eras optically linked with a simple plotting instru-
ment.4 This process has many limitations
including cost and time required since the
CBCT and stereophotogrammetry need to be
performed simultaneously to avoid changes in
facial expression that could lead to errors. More-
over, the procedure is slow, making distortion of
the scanned image more likely.5,6 Weinberg
found that 3D photogrammetry that has the
Genex camera system tends to be accurate and
precise.7
Advances in cone-beam computed tomogra-
phy (CBCT) have facilitated the recording of
facial integumental data. The advantages of this
method are the main reason for its increased
popularity including low dose radiation, rela-
tively high speed and small unit size compared to
conventional computed tomography (CT). In
fact, CBCT has become a routine examination
for the diagnosis and planning of orthognathic
surgeries. However, CBCT does not record the
texture or color of soft tissues.8
An alternative method of obtaining and
recording facial integumental data is 3D photo-
grammetry which is currently commercially avail-
able in a variety of imaging systems.1 A major
reason for using 3D digital photogrammetry is
the ability to capture surface data in high-resolu-
tion color at relatively fast speeds which is a con-
siderable advantage when working with young or
developmentally impaired subjects.7,9
Based on the method of scanning, available
systems for recording facial integumental infor-
mation can be divided into two types: laser sur-
face scanning and, more recently, light emitting
diode (LED) or white light scanning. Since LED
white light is innocuous to the human body, a
range of devices using white light scanning have
flooded the market; the devices differ consider-
ably in terms of cost, capture method, imaging
hardware and software.6 Moreover, based on the
method of data capture,1,10 there are two types
of devices that use LED white light: stereo-photo-
grammetry and structured-light systems. In ste-
reo-photogrammetry, two or more cameras
obtain the images from slightly different angles,
and, by triangulation, match the corresponding
features between the images to construct the 3D
surface. In a structured-light system, a 3D scan-
ner projects patterns of light and acquires the
distortions of patterns to calculate the 3D coordi-
nates of details on the object’s surface.
The Artec Eva 3D scanner uses white struc-
tured light technology making it safe for scan-
ning people. The device captures 16 frames per
second and simultaneously processes up to two
million points per second with high accuracy of
up to 0.1 mm. Three dimensional resolution is
0.5 mm and in color. For facial applications, its
accuracy and applicability has not been tested
(Fig. 1).
The present study was designed to compare
and evaluate the accuracy of these different types
of methods to generate 3D facial models by com-
paring with measurements made directly on the
face. The null hypotheses tested was no differ-
ence in accuracy of 3D facial integument meas-
urements using the following three techniques
compared to measuring integument facial fea-
tures directly: 1) volume wrapping 2D Images on
CBCT,11 2) volume wrapping the facial scan
using Artec 3D scanner on CBCT, and 3) facial
model generated by the Artec 3D scan itself with-
out any volume wrapping.
Materials and methods
Sample
The study protocol was approved by the Euro-
pean University College Research Committee.
The sample was comprised of 25 patients:
15 females and 10 males. Four subgroups were
created based upon the method of facial integu-
ment measurement: (1) direct anthropometric
facial (direct), (2) volume wrapping 2D images
on CBCT (2D wrap), (3) volume wrapping 3D
facial scan using Artec Eva on CBCT (3D wrap),
and (4) direct 3D face scan (3D scan).
Procedures
Each patient was scheduled for a diagnostic
CBCT scan using the Kodak 9500 Cone Beam 3D
System. Easily identifiable, reliable reference
points were chosen for the comparative measure-
ments. (Table 1 and Fig. 2) At the time of the
 Evaluating the accuracy of facial models obtained from volume wrapping
Table 1. Description of 26 anthropometric measure-
ments made on the face and left ear. (See Figs. 2 for
illustration of points.)
Descriptions of landmarks and measurements
(1) Endocanthion; innercanthal distance
(2) Exocanthion; lateral canthal width
(3) Exocanthion - endocanthion; right eye
fissure width
(4) Alare - alare; nasal width
(5) Sellion - subnasale; nasal height
(6) Subnasale - pronasale; nasal tip protusion
(7) Subnasale - highest point of columella;
columellar length
(8) Subnasale - stomion; overall upper labial
height
(9) Stomion - superior lower lip; lower lip
height
(10) Crista philtri superior; upper prolabia
width
(11) Crusta philtri inferior; lower prolabial
width
(12) Alar curvature - crista philtri superior;
facial insertion of alar base to crista philtri
superior
(13) Subnasale - crista philtri inferior; midpoint
of columella base to inferior of philtral column
(14) Subalare - crista philtri superior; labial
insertion of alar base to superior point of
philtral column
(15) Crista philtri inferior chelion; inferior
point of column to labial fissure
(16) Crista philtri superior - crista philtri
inferior; philtral length
(17) Trichion - glabella; forehead height
(18) Nasion - gnathion; face height
(19) Nasion - stomion; upper face height
(20) Subnasale - gnathion; lower face height
(21) Zygoma - zygoma; facial width
(22) Nasion - subnasale; nose height
(23) Subnasale - subnasale; columella width
(24) Chelion - chelion; mouth width
(25) Preaurale - postaurale; left ear width
(26) Superioraurale - subaurale; pina (left ear)
height
Figure 1. Artec Eva is a high-resolution 3D scanner based on white structured light technology. (For interpreta-
tion of the references to color in this figure legend, the reader is referred to the web version of this article.)
445
scan, 26 direct anthropometric facial measure-
ments were made directly on the patient’s face
with a sliding caliper.
Measure A 2D photograph was taken of the patient in
natural head position using a digital single-lens
En-En
Ex-Ex reflex camera (Nikon D3100 with 18 55 mm
Ex-En lens) at a standardized distance of 3 m. A facial
scan was also obtained using a white light scan
Al-Al
Se-Sn hand held Artec Eva 3D scanner.
Sn-Prn Each patient’s photograph, facial scan and
Sn-C’ CBCT scan were sent to Anatomage (San Jose,
Sn-Sto CA, USA) and 2 facial models were obtained
from Anatomage as follows: a) volume wrapping
Sto-Ll the 2D Images on the CBCT, and b) volume
Cphs-Cphs wrapping the facial scans on the CBCT
The third facial model was obtained directly
Cphi-Cphi by scanning the faces using Artec Eva 3D scanner
Ac-Cphs (without volume wrapping on CBCT) using the
Artec Studio software 12 (Artec Corp., Luxem-
borg) for calibrations (Fig. 3).
Sn-Cphim
Sbal-Cphs
Statistical analysis
Cphi-Ch
The facial measurements were repeated on the
Cphs-Cphi
two 3D facial models using Anato-model software
Tr-G and on the Artec Eva 3D scanner facial model.
N-Gn The measurements obtained from the 3D mod-
N-Sto
Sn-Gn els were compared with those taken directly
Zy-Zy from the face using paired t tests. Intra-examiner
N-Sn reliability was determined by repeating the same
Sn-Sn
Ch-Ch measurements two weeks later and comparing
Pra-Pa the results with a paired t test. The probability
Sa-Sba level of P  .01 was chosen to represent signifi-
cant differences. Measurement differences
446 Almulla et al

Table 2. Results of comparing direct facial measurements (direct) with three other anthropometric measurement
techniques, i.e. 2D wrap, 3D wrap and 3D scan. Note that 7 of 26 (26.9%) of measurements made by 2D wrap, 3D
wrap and/or 3D scan were significantly larger (P  .01) than the measurements made directly on the face, i.e. the
“gold standard”
Measurement Direct 2D wrap 3D wrap 3D scan
mean mean P sig mean P sig Mean P sig
Inner canthus En-En 29.57 29.88 .006 29.98 .002 29.99 .003
Inter-ala nose width Al-Al 35.66 35.85 .004 35.84 .004
Nasal tip protrusion Sn-Prn 10.67 11.22 .006 11.30 .004 11.30 .004
Columella length Sn-C’ 8.32 8.64 .006 8.68 .005 8.68 .005
Lower lip length Sto-Li 13.49 13.89 .003 13.92 .006 13.91 .006
Forehead height Tr-G 49.86 50.03 .008 50.23 .006
Face height N-Gn 105.22 105.43 .006 105.43 .007
Lower face height Sn-Gn 47.35 47.84 .003 48.00 .000 48.01 .000
Upper face height N-Sto 58.62 59.20 .001 59.33 .000 59.33 .000
Ear width (left) Pra-Pa 29.81 30.30 .000 30.29 .000

between any of the techniques greater than
0.5 mm were considered clinically significant.
Results
The reliability testing demonstrated no signifi-
cant differences upon repeated measures using
paired t tests. Using the 99% level of probability,
the largest difference between techniques was
for upper face height (0.71 mm) and the smallest
measurement difference was for forehead height
(0.17 mm)
Ten of the 26 measurements (34.5%) demon-
strated significant differences (P  .01). Direct
measurement technique values were significantly
smaller in 7 of the 10 (70.0%) measurements that
differed; 2D wrap values were significantly smaller
than 3D wrap and 3D scan values in 3 of 10
(30.0%) measurements that differed (Table 2).
Differences between the direct measurements
(gold standard) and the three other techniques
were calculated and plotted for the three varia-
bles demonstrated significance both statistically
and clinically, i.e. nasal tip protrusion (Sn-Prn),
lower face height (Sn0Gn) and upper face
height (N-Sto) (Fig. 4).
Discussion
Obtaining a precise 3D facial model is not only of
prime importance to orthodontists and surgeons,
but also to the patient. Simulating orthognathic
surgeries and orthodontic treatment planning
would not only help the operator but also elimi-
nate the uncertainty in the mind of the patient
thereby reducing the negative psychological
influences of the treatment. This can only be
achieved with an accurate 3D model of both the
soft tissue and the underlying skeletal structures.
The objective of this study was to verify the linear
accuracy and precision of direct facial measure-
ments (with a sliding caliper of 0.01 mm accu-
racy) compared to inteugmental measurements
obtained by 2-D wrapping on CBCT scans, and
facial scans with the Eva Artec scanner (both
wrapped and unwrapped on CBCT scans). Direct
facial measurements, i.e. direct anthropometric
measurements were used as the “gold standard”
to which three 3D facial model measurement
techniques were compared. In this study, four
groups were compared:
 For 2D wrap images, 2D frontal, left and right
profile photographs were taken with a Nikon
d90-18-55 lens and superimposed on a CBCT
image.
 For 3D wrap images, a 3D facial scan was
superimposed on a CBCT image.
 For 3D scan images, a 3-dimenstional facial
scan was performed with a hand held scanner
(Artec Eva model) which used structured
white light scan to capture facial contours.
Direct anthropometry is considered the gold
standard for in vivo soft-tissue assessment; it is
simple and relatively inexpensive, and it does not
require complex instrumentation. Various meth-
ods have been proposed to obtain equally accu-
rate 3D facial models, including 3D laser
scanning, video imaging, 3D stereo cameras,
 Evaluating the accuracy of facial models obtained from volume wrapping
Figure 2. Illustration of the landmarks and the 26 anthropometric measurements used in the study. A—face and left ear: B—inferior view of face; C—profile view
of face. (See Table 1 for description of points.)

447
 448
Almulla et al
Figure 3. Illustration of two measurements using Artec Studio 12 software on the facial scan image acquired by the Artec Eva scanner. (For interpretation of the
references to color in this figure legend, the reader is referred to the web version of this article.)
 Evaluating the accuracy of facial models obtained from volume wrapping 449

Figure 4. Differences between the direct measurements and the other three techniques, i.e. 2D wrap, 3D wrap
and 3D scan, were calculated, plotted and illustrated relative to the clinical significance guideline of 0.5 mm for
the three variables that were significant both statistically and clinically. The three facial measurements, i.e. N-Sto,
Sn-Prn and Sn-Gn are also illustrated on the profile face photograph.

digital color portraits, and volume wrapping. Of
these, volume wrapping is the least time-consum-
ing and easiest for the clinician, since the imag-
ing company performs most of the labor, by
superimposing 2D photographs on a CBCT. The
technique is now used routinely by orthodontists
and oral surgeons to simulate surgeries, but was
evaluated in comparison with direct measure-
ments of the face, by Premjani et al. They found
high concordance between the techniques for all
values evaluated, except for Columellar length
(Sn-C’). In our study, for the 2D wrapped models
we found differences in 5 other values as well.
These six values with statistically significant dif-
ferences (inner canthus, nasal tip protrusion,
columellar length, lower lip length, lower face
height and upper face height) were mostly verti-
cal measurements. However, the 2D wrapped val-
ues were closest to the control group, amongst
the 3 experimental groups.
We evaluated the 3D scans with the hand held
Artec scanner with and without volume wrapping
to find significant differences. We did not find
any significant differences between these two
groups. This was particularly evaluated, as we
wanted to check the accuracy of the 3D facial
scan, without a volume wrapping on a CBCT, as
a CBCT might not be mandated in all clinical
scenarios. Though the Artec Eva is a scanner that
has not been evaluated for clinical
measurements earlier, the results of this study
are encouraging and comparable to other stud-
ies evaluating accuracy of 3D photography appli-
cations and other imaging applications in
orthodontics.1,12,13
Measurements made directly on the face were
significantly smaller than at least one of the other
three measurement techniques in 7 of 26 meas-
urements (26.9%). Difference in values between
the direct and other techniques exceeded the
clinically significance guideline of 0.5 mm on
three occasions: (1) The greatest magnitude of
difference recorded (0.71 mm) that was found
statistically different (P  .01) was for upper face
height (N-Sto) between direct versus 3D wrap
and 3D scan. (2) Direct measurement for lower
face height (Sn-Gn) was 0.66 mm smaller than
3D scan. (3) Nasal tip projection (Sn-Prn) was
smaller by direct measurement by 0.63 mm than
3D wrap and 3D scan. These three vertical meas-
urements found smaller by direct measurement
may be considered clinically significant.
Difference in values between the remaining 4 of
7 direct measurements and the other techniques
did not exceeded 0.5 mm and therefore were con-
sidered clinically insignificant; any of three alterna-
tive techniques could be substituted for the direct
measurement method. Moreover, 19 of 26 meas-
urements (73.1%) were not significantly different
and could be substituted one for another.
450 Almulla et al
The relative ease of obtaining an accurate 3D
facial model represents a positive step forward in
orthodontic treatment planning. With the
decreases in cost and increases in the speed of
acquiring 3D facial models, the 3D virtual record
should soon replace traditional methods of
orthodontic record taking.
Conclusions
The direct technique for measuring extra oral
facial anthropometric parameters is the “gold
standard” to which three other measurement
techniques were compared. The null hypotheses
tested was no difference in accuracy of 3D facial
integument measurements of three indirect facial
measurement techniques compared to measuring
integument facial features directly. Important
results of the present study include the following:
 Direct technique measurements were signifi-
cantly smaller than the other three techniques
in 7 of 26 (26.8%) measurements at the 99%
probability level.
 Differences between 3 of 7 measurements
exceeded 0.5 mm and were deemed clinically
significant, i.e. upper face height (N-Sto),
lower face height (Sn-Gn) and nasal tip pro-
jection (Sn-Prn); these 3 direct measurements
cannot be readily substituted by 2D wrap, 3D
wrap or 3D scan measurement techniques.
 The remaining 23 of 26 measurements,
including the 4 of 7 measurements that were
statistically different but did not exceed the
0.5 mm clinical significance guidelines, could
be substituted by 2D wrap, 3D wrap or 3D
scan measurement techniques.
 Compared to the direct technique, 2D volume
wrap on CBCT values were closer than the val-
ues obtained from the 3D volume wrap and
3D CBCT techniques.
Based upon the conditions of the present study,
differences in values between direct measurement
and the other three techniques in 23 of 26 face
and ear measurements (88.5%) were neither sta-
tistically nor clinically significant and, therefore,
could be substituted one for the other, and dem-
onstrated a fairly high level of precision.
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