Clinical applicability of automated cephalometric landmark identification: Part I-Patient-related identification errors

Accuracy of cephalometric landmark identification by artificial intelligence platform versus expert orthodontist in unilateral cleft palate patients: A retrospective study

OBJECTIVE

The primary aim of the study was to evaluate the accuracy of automated artificial intelligence (AI) cephalometric landmark identification in cleft patients and compare it to landmarks identified by an expert orthodontist. The secondary objective was to compare cephalometric measurements obtained by both methods.

MATERIAL AND METHODS

A total of 112 pre-treatment lateral cephalometric radiographs of unilateral cleft palate patients were collected from the archives of the Department of Orthodontics, Faculty of Dentistry, Alexandria University following screening of all the records of patients treated in the period January 2019-December 2022 for eligibility. For each of the acquired radiographs, cephalometric tracing was performed by fully automated WebCeph™ landmark detection process and by manual identification of the landmarks by an expert orthodontist using OnyxCeph™ software. The traced radiographs were then imported into Photoshop software for evaluation of the (x,y) coordinates, in mm, for each of the identified landmarks (Primary outcome). Moreover, linear and angular measurements generated using WebCeph™ and OnyxCeph™ software were compared (secondary outcomes).

RESULTS

The coordinates of A-point, ANS, and Or showed statistically significant differences between both identification methods, with a mean difference between the two methods ranging between -0.86mm±2.15 and 3.15mm±6.07. None of the dental landmarks showed statistically significant differences between the two methods. None of the soft tissue landmarks showed statistically significant differences, except Ns y-coordinate. Several points showed clinically significant differences between both methods. The greatest mean differences in cephalometric measurements between the two methods were reported in nasolabial angle CotgSnLs (18.3±22.77̊) followed by Max1-NA (-8.86±17.46̊) and Max1-SN (-8.43±12.51̊).

CONCLUSIONS

The identification of cephalometric landmarks in cleft palate patients using the web-based AI platform is not as accurate as manual identification. Manual adjustment of landmarks following AI identification is advised.

Assessment of the quality of different commercial providers using artificial intelligence for automated cephalometric analysis compared to human orthodontic experts

PURPOSE

The aim of this investigation was to evaluate the accuracy of various skeletal and dental cephalometric parameters as produced by different commercial providers that make use of artificial intelligence (AI)-assisted automated cephalometric analysis and to compare their quality to a gold standard established by orthodontic experts.

METHODS

Twelve experienced orthodontic examiners pinpointed 15 radiographic landmarks on a total of 50 cephalometric X‑rays. The landmarks were used to generate 9 parameters for orthodontic treatment planning. The "humans' gold standard" was defined by calculating the median value of all 12 human assessments for each parameter, which in turn served as reference values for comparisons with results given by four different commercial providers of automated cephalometric analyses (DentaliQ.ortho [CellmatiQ GmbH, Hamburg, Germany], WebCeph [AssembleCircle Corp, Seongnam-si, Korea], AudaxCeph [Audax d.o.o., Ljubljana, Slovenia], CephX [Orca Dental AI, Herzliya, Israel]). Repeated measures analysis of variances (ANOVAs) were calculated and Bland-Altman plots were generated for comparisons.

RESULTS

The results of the repeated measures ANOVAs indicated significant differences between the commercial providers' predictions and the humans' gold standard for all nine investigated parameters. However, the pairwise comparisons also demonstrate that there were major differences among the four commercial providers. While there were no significant mean differences between the values of DentaliQ.ortho and the humans' gold standard, the predictions of AudaxCeph showed significant deviations in seven out of nine parameters. Also, the Bland-Altman plots demonstrate that a reduced precision of AI predictions must be expected especially for values attributed to the inclination of the incisors.

CONCLUSION

Fully automated cephalometric analyses are promising in terms of timesaving and avoidance of individual human errors. At present, however, they should only be used under supervision of experienced clinicians.

Artificial intelligence for orthodontic diagnosis and treatment planning: A scoping review

OBJECTIVES

To provide an overview of artificial intelligence (AI) applications in orthodontic diagnosis and treatment planning, and to evaluate whether AI improves accuracy, reliability, and time efficiency compared to expert-based manual approaches, while highlighting its current limitations.

DATA

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

SOURCES

An electronic search was performed on PubMed, Web of Science, and Embase electronic databases. Additional studies were identified from Google Scholar and by hand searching through included studies. The search was carried out until June 2023 without restriction of language and publication year.

STUDY SELECTION

After applying the selection criteria, 71 articles were included in the review. The main research areas were classified into three domains based on the purpose of AI: diagnostics (n = 29), landmark identification (n = 20) and treatment planning (n = 22).

CONCLUSION

This scoping review shows that AI can be used in various orthodontic diagnosis and treatment planning applications, with anatomical landmark detection being the most studied domain. While AI shows potential in improving time efficiency and reducing operator variability, the accuracy and reliability have not yet consistently surpassed those of expert clinicians. At all moments, human supervision remains essential. Further advances and optimizations are necessary to strive towards automated patient-specific treatment planning.

CLINICAL SIGNIFICANCE

AI in orthodontics has shown its ability to serve as a decision-support system, thereby enhancing the efficiency of diagnostics and treatment planning within orthodontics digital workflow."

A Comparative Study of Deep Learning and Manual Methods for Identifying Anatomical Landmarks through Cephalometry and Cone-Beam Computed Tomography: A Systematic Review and Meta-Analysis

Background: Researchers have noted that the advent of artificial intelligence (AI) heralds a promising era, with potential to significantly enhance diagnostic and predictive abilities in clinical settings. The aim of this meta-analysis is to evaluate the discrepancies in identifying anatomical landmarks between AI and manual approaches. Methods: A comprehensive search strategy was employed, incorporating controlled vocabulary (MeSH) and free-text terms. This search was conducted by two reviewers to identify published systematic reviews. Three major electronic databases, namely, Medline via PubMed, the Cochrane database, and Embase, were searched up to May 2024. Results: Initially, 369 articles were identified. After conducting a comprehensive search and applying strict inclusion criteria, a total of ten studies were deemed eligible for inclusion in the meta-analysis. The results showed that the average difference in detecting anatomical landmarks between artificial intelligence and manual approaches was 0.35, with a 95% confidence interval (CI) ranging from −0.09 to 0.78. Additionally, the overall effect between the two groups was found to be insignificant. Upon further analysis of the subgroup of cephalometric radiographs, it was determined that there were no significant differences between the two groups in terms of detecting anatomical landmarks. Similarly, the subgroup of cone-beam computed tomography (CBCT) revealed no significant differences between the groups. Conclusions: In summary, the study concluded that the use of artificial intelligence is just as effective as the manual approach when it comes to detecting anatomical landmarks, both in general and in specific contexts such as cephalometric radiographs and CBCT evaluations.

Can artificial intelligence-driven cephalometric analysis replace manual tracing? A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to investigate the accuracy and efficiency of artificial intelligence (AI)-driven automated landmark detection for cephalometric analysis on two-dimensional (2D) lateral cephalograms and three-dimensional (3D) cone-beam computed tomographic (CBCT) images.

SEARCH METHODS

An electronic search was conducted in the following databases: PubMed, Web of Science, Embase, and grey literature with search timeline extending up to January 2024.

SELECTION CRITERIA

Studies that employed AI for 2D or 3D cephalometric landmark detection were included.

DATA COLLECTION AND ANALYSIS

The selection of studies, data extraction, and quality assessment of the included studies were performed independently by two reviewers. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A meta-analysis was conducted to evaluate the accuracy of the 2D landmarks identification based on both mean radial error and standard error.

RESULTS

Following the removal of duplicates, title and abstract screening, and full-text reading, 34 publications were selected. Amongst these, 27 studies evaluated the accuracy of AI-driven automated landmarking on 2D lateral cephalograms, while 7 studies involved 3D-CBCT images. A meta-analysis, based on the success detection rate of landmark placement on 2D images, revealed that the error was below the clinically acceptable threshold of 2 mm (1.39 mm; 95% confidence interval: 0.85-1.92 mm). For 3D images, meta-analysis could not be conducted due to significant heterogeneity amongst the study designs. However, qualitative synthesis indicated that the mean error of landmark detection on 3D images ranged from 1.0 to 5.8 mm. Both automated 2D and 3D landmarking proved to be time-efficient, taking less than 1 min. Most studies exhibited a high risk of bias in data selection (n = 27) and reference standard (n = 29).

CONCLUSION

The performance of AI-driven cephalometric landmark detection on both 2D cephalograms and 3D-CBCT images showed potential in terms of accuracy and time efficiency. However, the generalizability and robustness of these AI systems could benefit from further improvement.

REGISTRATION

PROSPERO: CRD42022328800.

Orthodontic Implementation of Machine Learning Algorithms for Predicting Some Linear Dental Arch Measurements and Preventing Anterior Segment Malocclusion: A Prospective Study

Background and Objectives: Orthodontics is a field that has seen significant advancements in recent years, with technology playing a crucial role in improving diagnosis and treatment planning. The study aimed to implement artificial intelligence to predict the arch width as a preventive measure to avoid future crowding in growing patients or even in adult patients seeking orthodontic treatment as a tool for orthodontic diagnosis. Materials and Methods: Four hundred and fifty intraoral scan (IOS) images were selected from orthodontic patients seeking treatment in private orthodontic centers. Real inter-canine, inter-premolar, and inter-molar widths were measured digitally. Two of the main machine learning models were used: the Python programming language and machine learning algorithms, implementing the data on k-nearest neighbor and linear regression. Results: After the dataset had been implemented on the two ML algorithms, linear regression and k-nearest neighbor, the evaluation metric shows that KNN gives better prediction accuracy than LR does. The resulting accuracy was around 99%. Conclusions: it is possible to leverage machine learning to enhance orthodontic diagnosis and treatment planning by predicting linear dental arch measurements and preventing anterior segment malocclusion.

Application of Artificial Intelligence in Orthodontics: Current State and Future Perspectives

In recent years, there has been the notable emergency of artificial intelligence (AI) as a transformative force in multiple domains, including orthodontics. This review aims to provide a comprehensive overview of the present state of AI applications in orthodontics, which can be categorized into the following domains: (1) diagnosis, including cephalometric analysis, dental analysis, facial analysis, skeletal-maturation-stage determination and upper-airway obstruction assessment; (2) treatment planning, including decision making for extractions and orthognathic surgery, and treatment outcome prediction; and (3) clinical practice, including practice guidance, remote care, and clinical documentation. We have witnessed a broadening of the application of AI in orthodontics, accompanied by advancements in its performance. Additionally, this review outlines the existing limitations within the field and offers future perspectives.

Application of Artificial Intelligence (AI) in a Cephalometric Analysis: A Narrative Review

In recent years, the application of artificial intelligence (AI) has become more and more widespread in medicine and dentistry. It may contribute to improved quality of health care as diagnostic methods are getting more accurate and diagnostic errors are rarer in daily medical practice. The aim of this paper was to present data from the literature on the effectiveness of AI in orthodontic diagnostics based on the analysis of lateral cephalometric radiographs. A review of the literature from 2009 to 2023 has been performed using PubMed, Medline, Scopus and Dentistry & Oral Sciences Source databases. The accuracy of determining cephalometric landmarks using widely available commercial AI-based software and advanced AI algorithms was presented and discussed. Most AI algorithms used for the automated positioning of landmarks on cephalometric radiographs had relatively high accuracy. At the same time, the effectiveness of using AI in cephalometry varies depending on the algorithm or the application type, which has to be accounted for during the interpretation of the results. In conclusion, artificial intelligence is a promising tool that facilitates the identification of cephalometric landmarks in everyday clinical practice, may support orthodontic treatment planning for less experienced clinicians and shorten radiological examination in orthodontics. In the future, AI algorithms used for the automated localisation of cephalometric landmarks may be more accurate than manual analysis.

Automatic recognition of cephalometric landmarks via multi-scale sampling strategy

The identification of head landmarks in cephalometric analysis significantly contributes in the anatomical localization of maxillofacial tissues for orthodontic and orthognathic surgery. However, the existing methods face the limitations of low accuracy and cumbersome identification process. In this pursuit, the present study proposed an automatic target recognition algorithm called Multi-Scale YOLOV3 (MS-YOLOV3) for the detection of cephalometric landmarks. It was characterized by multi-scale sampling strategies for shallow and deep features at varied resolutions, and especially contained the module of spatial pyramid pooling (SPP) for highest resolution. The proposed method was quantitatively and qualitatively compared with the classical YOLOV3 algorithm on the two data sets of public lateral cephalograms, undisclosed anterior-posterior (AP) cephalograms, respectively, for evaluating the performance. The proposed MS-YOLOV3 algorithm showed better robustness with successful detection rates (SDR) of 80.84% within 2 mm, 93.75% within 3 mm, and 98.14% within 4 mm for lateral cephalograms, and 85.75% within 2 mm, 92.87% within 3 mm, and 96.66% within 4 mm for AP cephalograms, respectively. It was concluded that the proposed model could be robustly used to label the cephalometric landmarks on both lateral and AP cephalograms for the clinical application in orthodontic and orthognathic surgery.

Clinical Applications of Artificial Intelligence and Machine Learning in Children with Cleft Lip and Palate-A Systematic Review

OBJECTIVE

The objective of this systematic review was (a) to explore the current clinical applications of AI/ML (Artificial intelligence and Machine learning) techniques in diagnosis and treatment prediction in children with CLP (Cleft lip and palate), (b) to create a qualitative summary of results of the studies retrieved.

MATERIALS AND METHODS

An electronic search was carried out using databases such as PubMed, Scopus, and the Web of Science Core Collection. Two reviewers searched the databases separately and concurrently. The initial search was conducted on 6 July 2021. The publishing period was unrestricted; however, the search was limited to articles involving human participants and published in English. Combinations of Medical Subject Headings (MeSH) phrases and free text terms were used as search keywords in each database. The following data was taken from the methods and results sections of the selected papers: The amount of AI training datasets utilized to train the intelligent system, as well as their conditional properties; Unilateral CLP, Bilateral CLP, Unilateral Cleft lip and alveolus, Unilateral cleft lip, Hypernasality, Dental characteristics, and sagittal jaw relationship in children with CLP are among the problems studied.

RESULTS

Based on the predefined search strings with accompanying database keywords, a total of 44 articles were found in Scopus, PubMed, and Web of Science search results. After reading the full articles, 12 papers were included for systematic analysis.

CONCLUSIONS

Artificial intelligence provides an advanced technology that can be employed in AI-enabled computerized programming software for accurate landmark detection, rapid digital cephalometric analysis, clinical decision-making, and treatment prediction. In children with corrected unilateral cleft lip and palate, ML can help detect cephalometric predictors of future need for orthognathic surgery.

Where Is the Artificial Intelligence Applied in Dentistry? Systematic Review and Literature Analysis

This literature research had two main objectives. The first objective was to quantify how frequently artificial intelligence (AI) was utilized in dental literature from 2011 until 2021. The second objective was to distinguish the focus of such publications; in particular, dental field and topic. The main inclusion criterium was an original article or review in English focused on dental utilization of AI. All other types of publications or non-dental or non-AI-focused were excluded. The information sources were Web of Science, PubMed, Scopus, and Google Scholar, queried on 19 April 2022. The search string was “artificial intelligence” AND (dental OR dentistry OR tooth OR teeth OR dentofacial OR maxillofacial OR orofacial OR orthodontics OR endodontics OR periodontics OR prosthodontics). Following the removal of duplicates, all remaining publications were returned by searches and were screened by three independent operators to minimize the risk of bias. The analysis of 2011–2021 publications identified 4413 records, from which 1497 were finally selected and calculated according to the year of publication. The results confirmed a historically unprecedented boom in AI dental publications, with an average increase of 21.6% per year over the last decade and a 34.9% increase per year over the last 5 years. In the achievement of the second objective, qualitative assessment of dental AI publications since 2021 identified 1717 records, with 497 papers finally selected. The results of this assessment indicated the relative proportions of focal topics, as follows: radiology 26.36%, orthodontics 18.31%, general scope 17.10%, restorative 12.09%, surgery 11.87% and education 5.63%. The review confirms that the current use of artificial intelligence in dentistry is concentrated mainly around the evaluation of digital diagnostic methods, especially radiology; however, its implementation is expected to gradually penetrate all parts of the profession.