Can Intraoral Photography Replace Plaster and Digital Models in Clinical Practice? A Preliminary Investigation
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About This Presentation
photography
Slide Content
84 JCO/FEBRUARY 2019k] .'3, -nc.
LAURANCE JERROLD, DDS, JD
MICHAEL SCHULTE, DDS, PhD
JESSIE ISAACS HENRY, DDS
Can Intraoral Photography Replace
Plaster and Digital Models in Clinical
Practice? A Preliminary Investigation
Orthodontists have been creating study mod-
els for more than 100 years. Current methods of
acquisition include conventional impressions
poured in plaster, plaster casts converted to
three-dimensional representations, digital study
models constructed from impressions that are sent
out to be scanned, and direct scanning of the pa-
tient’s dentition for conversion to 3D imagery. Each
medium carries its own set of pluses and minuses.
Over the past decade, we have been repeat-
edly asked whether the current standard of care for
diagnosis and treatment planning requires the ac-
quisition of plaster or digital study models, or if
photographs can be used instead. The question is
actually threefold: first, is it feasible to replace ei-
ther of those diagnostic modalities with intraoral
photography; second, does doing so fall within the
standard of care; and finally, does doing so consti-
tute “best practice”?
While each state has its own definition of the
standard of care, the following is a fairly accurate
composite.
1
The standard of care conforms to the
degree of care and skill as possessed by the aver-
age practitioner in good standing who practices the
same specialty, utilizing the degree of knowledge
available at that time. This incorporates the con-
cept of how the average practitioner would act un-
der the same or similar circumstances—temporal-
ly, clinically, and geographically. It also
acknowledges that there may be two or more
schools of thought regarding appropriate delivery
of health-care services, recognizing acts performed
by a “respectable minority” of practitioners as fall-
ing within the standard of care. This criterion was
clearly elucidated in the McCourt decision.
2
“Best practice” has many definitions, but the
one most suited to health care was articulated by
Bretschneider and colleagues.
3
For something to
be considered a best practice, all relevant ap-
proaches must be compared. This requires an
evaluation of the clinimetrics currently being em-
ployed. Clinimetrics is a form of clinical epi
C
ontemporary tools used to support the clinical orthodontic examination
include cephalometric and panoramic radiography and extraoral and
intraoral photography. In addition, study models have traditionally been
fabricated to evaluate tooth-size/arch-length discrepancies, crowding, spac-
ing, intra- and interarch dentoalveolar relationships, inclinations, and rota-
tions; to research the efficacy of various treatments; and to validate degrees
of severity for reimbursement considerations. ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
LAURANCE JERROLD, DDS, JD
MICHAEL SCHULTE, DDS, PhD
JESSIE ISAACS HENRY, DDS
Can Intraoral Photography Replace
Plaster and Digital Models in Clinical
Practice? A Preliminary Investigation
Orthodontists have been creating study mod-
els for more than 100 years. Current methods of
acquisition include conventional impressions
poured in plaster, plaster casts converted to
three-dimensional representations, digital study
models constructed from impressions that are sent
out to be scanned, and direct scanning of the pa-
tient’s dentition for conversion to 3D imagery. Each
medium carries its own set of pluses and minuses.
Over the past decade, we have been repeat-
edly asked whether the current standard of care for
diagnosis and treatment planning requires the ac-
quisition of plaster or digital study models, or if
photographs can be used instead. The question is
actually threefold: first, is it feasible to replace ei-
ther of those diagnostic modalities with intraoral
photography; second, does doing so fall within the
standard of care; and finally, does doing so consti-
tute “best practice”?
While each state has its own definition of the
standard of care, the following is a fairly accurate
composite.
1
The standard of care conforms to the
degree of care and skill as possessed by the aver-
age practitioner in good standing who practices the
same specialty, utilizing the degree of knowledge
available at that time. This incorporates the con-
cept of how the average practitioner would act un-
der the same or similar circumstances—temporal-
ly, clinically, and geographically. It also
acknowledges that there may be two or more
schools of thought regarding appropriate delivery
of health-care services, recognizing acts performed
by a “respectable minority” of practitioners as fall-
ing within the standard of care. This criterion was
clearly elucidated in the McCourt decision.
2
“Best practice” has many definitions, but the
one most suited to health care was articulated by
Bretschneider and colleagues.
3
For something to
be considered a best practice, all relevant ap-
proaches must be compared. This requires an
evaluation of the clinimetrics currently being em-
ployed. Clinimetrics is a form of clinical epi
C
ontemporary tools used to support the clinical orthodontic examination
include cephalometric and panoramic radiography and extraoral and
intraoral photography. In addition, study models have traditionally been
fabricated to evaluate tooth-size/arch-length discrepancies, crowding, spac-
ing, intra- and interarch dentoalveolar relationships, inclinations, and rota-
tions; to research the efficacy of various treatments; and to validate degrees
of severity for reimbursement considerations. ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
85VOLUME LIII NUMBER 2
Dr. Isaacs HenryDr. SchulteDr. Jerrold
and width requirements, and evaluate arch sym-
metry.
3. Intraoral and/or panoramic radiographs to as-
sess the condition and developmental status of the teeth and associated structures, and to identify any dental anomalies or pathology. 4.
Cephalometric radiographs to permit evaluation
of the size, shape, and positions of the craniofacial structures and dentition and to aid in the identifi-
cation of skeletal anomalies or pathology.
(It is interesting to note that the AAO Com-
mittee on Medically Necessary Orthodontic Care has proposed that the minimum records needed for submission to the National Association of Den-
tal Plans, used to determine whether a patient re-
quires orthodontic treatment for medical reasons, consist of a panoramic film, cephalometric ra-
diograph[s], and intraoral and extraoral photo-
graphs.
6
Study models are not included on this list.)
No additional explanation is provided for the
AAO Clinical Practice Guidelines, but these re-
cords are the ones that have been acquired since the beginning of orthodontics. Plaster casts allow tooth-size and arch-length measurements to be made for diagnostic purposes, allow cranial and dentoalveolar measurements to be obtained for research, are used as measuring tools for ABO certification, and serve as medicolegal records.
7, 8
Plaster casts provide important information about overbite, overjet, and transverse dimensions, as well as dental anatomy, alveolar bone shape, and gingival conformation.
9
They are the only 3D di-
agnostic record that can adequately represent the dentition in functional occlusion, and they allow the practitioner to evaluate the teeth and occlusion
demiology that evaluates the efficacy of treatments and diagnostic tests; according to Han and associ-
ates, it encompasses the areas of “biostatistics, epidemiology, clinical decision analysis, risk-
benefit analysis, cost benefit analysis and cost ef-
fectiveness analysis.”
4
Essentially, it weighs and
measures the factors involved in the clinical decision-making process.
This article addresses the diagnostic value or
utility of study models in assessing intra- and interarch dental relationships for the development of a treatment plan that falls within the parameters of best practices and a generally accepted standard of care. Diagnostic utility or value will be import-
ant, both from an objective and a subjective per-
spective, in determining whether the substitution of photography for model acquisition will affect the diagnosis, the method of treatment or mecha-
notherapy, or the outcome of the treatment. We will deal only with the diagnostic component, since the treatment and clinical outcome both take place after the diagnosis and treatment plan have been established.
Plaster Casts
The AAO’s Clinical Practice Guidelines for
Orthodontics and Dentofacial Orthopedics,
5
while
recognizing that the criteria will vary from case to case, recommends taking the following pretreat-
ment diagnostic records: 1.
Extraoral and intraoral images to supplement
clinical findings. 2.
Dental casts to assess intra- and interarch rela-
tionships of the teeth, help determine arch length
Dr. Jerrold is the Program Director and Drs. Schulte and Isaacs Henry are former residents, Orthodontic Residency Program, NYU Langone Hospital
Brooklyn, 150 55th St., Brooklyn, NY 11220. E-mail Dr. Jerrold at [email protected]. ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
Dr. Isaacs HenryDr. SchulteDr. Jerrold
and width requirements, and evaluate arch sym-
metry.
3. Intraoral and/or panoramic radiographs to as-
sess the condition and developmental status of the teeth and associated structures, and to identify any dental anomalies or pathology. 4.
Cephalometric radiographs to permit evaluation
of the size, shape, and positions of the craniofacial structures and dentition and to aid in the identifi-
cation of skeletal anomalies or pathology.
(It is interesting to note that the AAO Com-
mittee on Medically Necessary Orthodontic Care has proposed that the minimum records needed for submission to the National Association of Den-
tal Plans, used to determine whether a patient re-
quires orthodontic treatment for medical reasons, consist of a panoramic film, cephalometric ra-
diograph[s], and intraoral and extraoral photo-
graphs.
6
Study models are not included on this list.)
No additional explanation is provided for the
AAO Clinical Practice Guidelines, but these re-
cords are the ones that have been acquired since the beginning of orthodontics. Plaster casts allow tooth-size and arch-length measurements to be made for diagnostic purposes, allow cranial and dentoalveolar measurements to be obtained for research, are used as measuring tools for ABO certification, and serve as medicolegal records.
7, 8
Plaster casts provide important information about overbite, overjet, and transverse dimensions, as well as dental anatomy, alveolar bone shape, and gingival conformation.
9
They are the only 3D di-
agnostic record that can adequately represent the dentition in functional occlusion, and they allow the practitioner to evaluate the teeth and occlusion
demiology that evaluates the efficacy of treatments and diagnostic tests; according to Han and associ-
ates, it encompasses the areas of “biostatistics, epidemiology, clinical decision analysis, risk-
benefit analysis, cost benefit analysis and cost ef-
fectiveness analysis.”
4
Essentially, it weighs and
measures the factors involved in the clinical decision-making process.
This article addresses the diagnostic value or
utility of study models in assessing intra- and interarch dental relationships for the development of a treatment plan that falls within the parameters of best practices and a generally accepted standard of care. Diagnostic utility or value will be import-
ant, both from an objective and a subjective per-
spective, in determining whether the substitution of photography for model acquisition will affect the diagnosis, the method of treatment or mecha-
notherapy, or the outcome of the treatment. We will deal only with the diagnostic component, since the treatment and clinical outcome both take place after the diagnosis and treatment plan have been established.
Plaster Casts
The AAO’s Clinical Practice Guidelines for
Orthodontics and Dentofacial Orthopedics,
5
while
recognizing that the criteria will vary from case to case, recommends taking the following pretreat-
ment diagnostic records: 1.
Extraoral and intraoral images to supplement
clinical findings. 2.
Dental casts to assess intra- and interarch rela-
tionships of the teeth, help determine arch length
Dr. Jerrold is the Program Director and Drs. Schulte and Isaacs Henry are former residents, Orthodontic Residency Program, NYU Langone Hospital
Brooklyn, 150 55th St., Brooklyn, NY 11220. E-mail Dr. Jerrold at [email protected]. ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
86 JCO/FEBRUARY 2019
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
from views that cannot be obtained by a clinical
exam alone.
7
Santoro and colleagues added that
only plaster casts provide tactile input, unlike oth-
er modeling methods, although the effect of this
sensory input has never been studied.
10
Bell com-
pared the use of plaster or stone casts with that of
photographs for identification purposes in dental
forensics.
11
Drawbacks of plaster casts include dimen-
sional deformation caused by variations in mois-
ture absorption or loss; deformation of the impres-
sion material due to undercuts; reduced efficiency
from the time required to retrieve the casts and
from damage, misplacement, or loss of models; the
time and effort spent in hand-measuring models;
and the difficulty and cost of diagnostic setups. In
addition, there are the problems of storage space,
proximity, and cost.
12
Mok and colleagues pointed
out that each set of models requires 700cm
3
of
space for some period of years, depending on the
state’s statute of limitations and dental practice act,
thus creating a significant financial burden, par-
ticularly in urban areas.
13
Duplication and shipping
of plaster models for consultations can be costly
and time-consuming.
14
Multiple sets of models are
needed in some cases, and because these records
are often acquired midtreatment, orthodontic
brackets or wires may distort the impressions and
compromise accuracy.
15
Although Hove and colleagues contended
that traditional plaster models provide the best
quantitative data for clinical analysis,
16
photo-
graphs have an advantage in terms of qualitative
data. In any case, the differences are so minimal
as to make the two types of data acquisition virtu-
ally equal in providing epidemiological and diag-
nostic clinical information.
Finally, it should be noted that study models—
certainly plaster, and to some degree digital—are
the only records that can be articulated in centric
relation as opposed to centric occlusion. Even if this
manner of recording the maxillomandibular rela-
tionship may sometimes be desirable or indicated,
however, it is not performed in the overwhelming
majority of orthodontic cases. According to Ellis,
articulating models in centric relation “does not
meaningfully influence treatment decisions,” main-
ly because of the lack of reproducibility of the reg-
istration.
17
Keating and colleagues observed that
while orthodontic diagnoses, outcomes, and treat-
ment changes have traditionally been documented
with plaster casts, there are many other ways to
record occlusal relationships.
18
Based on 74 studies,
they documented 19 different methods, 12 of which
involved the use of intraoral scanning devices and
digital study models, and four the use of intraoral
photography.
Digital Models
The employment of a method other than plas-
ter casts to record information relating to intra- and
interarch occlusal relationships would require
equally accurate measurements, or at least mea-
surements that were “accurate within clinically
acceptable parameters.” Santoro and colleagues
found that measurements made from OrthoCAD*
digital models were universally smaller than those
obtained from plaster casts.
10
The differences in
tooth-size measurements, ranging from .016mm to
.038mm, were statistically significant but clinical-
ly nonsignificant. The greatest errors were in mea-
suring overbite (about .5mm) and overjet (about
1mm)—again, deemed to be clinically nonsignif-
icant. On the other hand, Goonewardene and col-
leagues, who referred to plaster casts as the “gold
standard,” reported digital measurements that were
routinely larger than those obtained by direct mea-
surement of casts with calipers.
19
Their differenc-
es were also statistically significant but not clini-
cally significant, as corroborated by other
researchers.
20
In summary, “clinically acceptable
accuracy” can be defined as falling within 1mm
of the actual value or, for some specific conditions,
within 2mm.
Perhaps the most exhaustive review was un-
dertaken by Fleming and colleagues, who found
the mean differences between plaster and digital
model measurements to be .25mm for transverse,
tooth-size, and other linear dimensions; .65mm for
tooth-size/arch-length evaluations; and .75mm for
Bolton discrepancies.
21
Although none of these
differences was deemed to be clinically significant,
a distinction was made for Little’s Irregularity In-?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
from views that cannot be obtained by a clinical
exam alone.
7
Santoro and colleagues added that
only plaster casts provide tactile input, unlike oth-
er modeling methods, although the effect of this
sensory input has never been studied.
10
Bell com-
pared the use of plaster or stone casts with that of
photographs for identification purposes in dental
forensics.
11
Drawbacks of plaster casts include dimen-
sional deformation caused by variations in mois-
ture absorption or loss; deformation of the impres-
sion material due to undercuts; reduced efficiency
from the time required to retrieve the casts and
from damage, misplacement, or loss of models; the
time and effort spent in hand-measuring models;
and the difficulty and cost of diagnostic setups. In
addition, there are the problems of storage space,
proximity, and cost.
12
Mok and colleagues pointed
out that each set of models requires 700cm
3
of
space for some period of years, depending on the
state’s statute of limitations and dental practice act,
thus creating a significant financial burden, par-
ticularly in urban areas.
13
Duplication and shipping
of plaster models for consultations can be costly
and time-consuming.
14
Multiple sets of models are
needed in some cases, and because these records
are often acquired midtreatment, orthodontic
brackets or wires may distort the impressions and
compromise accuracy.
15
Although Hove and colleagues contended
that traditional plaster models provide the best
quantitative data for clinical analysis,
16
photo-
graphs have an advantage in terms of qualitative
data. In any case, the differences are so minimal
as to make the two types of data acquisition virtu-
ally equal in providing epidemiological and diag-
nostic clinical information.
Finally, it should be noted that study models—
certainly plaster, and to some degree digital—are
the only records that can be articulated in centric
relation as opposed to centric occlusion. Even if this
manner of recording the maxillomandibular rela-
tionship may sometimes be desirable or indicated,
however, it is not performed in the overwhelming
majority of orthodontic cases. According to Ellis,
articulating models in centric relation “does not
meaningfully influence treatment decisions,” main-
ly because of the lack of reproducibility of the reg-
istration.
17
Keating and colleagues observed that
while orthodontic diagnoses, outcomes, and treat-
ment changes have traditionally been documented
with plaster casts, there are many other ways to
record occlusal relationships.
18
Based on 74 studies,
they documented 19 different methods, 12 of which
involved the use of intraoral scanning devices and
digital study models, and four the use of intraoral
photography.
Digital Models
The employment of a method other than plas-
ter casts to record information relating to intra- and
interarch occlusal relationships would require
equally accurate measurements, or at least mea-
surements that were “accurate within clinically
acceptable parameters.” Santoro and colleagues
found that measurements made from OrthoCAD*
digital models were universally smaller than those
obtained from plaster casts.
10
The differences in
tooth-size measurements, ranging from .016mm to
.038mm, were statistically significant but clinical-
ly nonsignificant. The greatest errors were in mea-
suring overbite (about .5mm) and overjet (about
1mm)—again, deemed to be clinically nonsignif-
icant. On the other hand, Goonewardene and col-
leagues, who referred to plaster casts as the “gold
standard,” reported digital measurements that were
routinely larger than those obtained by direct mea-
surement of casts with calipers.
19
Their differenc-
es were also statistically significant but not clini-
cally significant, as corroborated by other
researchers.
20
In summary, “clinically acceptable
accuracy” can be defined as falling within 1mm
of the actual value or, for some specific conditions,
within 2mm.
Perhaps the most exhaustive review was un-
dertaken by Fleming and colleagues, who found
the mean differences between plaster and digital
model measurements to be .25mm for transverse,
tooth-size, and other linear dimensions; .65mm for
tooth-size/arch-length evaluations; and .75mm for
Bolton discrepancies.
21
Although none of these
differences was deemed to be clinically significant,
a distinction was made for Little’s Irregularity In-?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
87VOLUME LIII NUMBER 2
JERROLD, SCHULTE, ISAACS HENRY
pressions and the corresponding plaster casts alto-
gether.
24
Using dry skulls, they compared caliper
measurements of the actual teeth with those ob-
tained from a Carestream** CBCT and a Cadent
iTero*** intraoral scanner. The CBCT measure-
ments agreed with the actual measurements with-
in a range of .88mm-.99mm (except for the bucco-
lingual dimension of the lower anterior teeth,
which was .65mm), while the scanned measure-
ments agreed within .92mm-.99mm. The conclu-
sion was that both CBCT and the digital scanner
produced results that were “interchangeable” with
manual measurements.
Photographs
Callahan brought up the issue that serves as
the basis of this article by stating that in contem-
porary practice, a preliminary diagnosis and treat-
ment plan are often based on the clinical evaluation
supplemented only by photographs and radio-
graphs.
7
He questioned whether study models
would add any significant diagnostic data that
would result in a change of the provisional diag-
nosis or treatment plan.
Color photography can distinguish between
healthy and diseased tissue and can identify such
pathological findings as “white patches, inflam-
mation, ulceration, burns, lacerations, carcinoma,
. . . enamel translucency, decay, erosion and abra-
sion, as well as cervical dentin exposure and scle-
rosis, . . . shade analysis . . . and bleaching,” along
with other observations that cannot be made from
plaster casts or 3D imaging.
25
The following photo
graphic findings should routinely be recorded for
medicolegal documentation, formulation of a di-
agnosis and treatment plan, and assessment of the treatment outcome. Healthy vs. diseased tissue: Documenting poor oral hygiene is a cardinal concern. Orthodontic treatment should not be initiated or continued when hygiene is poor, since inflammation can rap-
idly lead to periodontal breakdown.
dex, averaging 3.75mm, and various occlusal indi-
ces (Peer Assessment Rating; Index of Complexi-
ty, Outcome, and Need; and ABO), averaging about 2mm each. In a clinical context, replacing plaster casts with digital models resulted in a change in diagnosis roughly 13% of the time, but changes in the actual treatment plan occurred in only 6% of the cases studied.
Arch-length analysis is one of the most com-
mon assessments performed with plaster casts. Leifert and colleagues found a difference in space analysis of less than .5mm between plaster casts and digital models, concluding once more that there was no clinical significance to the results.
22
One problem with their study was the use of a traditional brass-wire method to evaluate the avail-
able arch length; it was unclear whether the arch perimeter was measured at the center, off-center to the buccal side, or off-center to the lingual side of the ridge. Because opinions of where the teeth should sit in each arch may vary, this measurement could certainly make a clinical difference. Still, if the methodology of the analysis is consistent, it will not matter whether the measurement is made on plaster or on a digital image.
In a report by Mok and colleagues, 24% of
plaster casts could not be used because of damage, leading to the conclusion that—all else being equal—digital models are superior to plaster.
13
Therefore, if models are being saved for medico-
legal reasons, the use of plaster casts would not guarantee the permanence of those records. Mok and colleagues found that “2-dimensional imaging can be used as an alternative to casts in the assess-
ment of malocclusion and orthodontic treatment need.” It is interesting that they referred to digital models as 2D rather than 3D. This is because any individual view of a scanned model is a 2D im-
age—the same as a photograph. The only advan-
tage of 3D digital imagery is that all three dimen-
sions can be viewed by looking at multiple 2D images, one at a time. Magness admonished that while 3D views are “intriguing, valuable and in-
forming, orthodontists shouldn’t abandon 2-D views” as a format for recording data.
23
Akyalcin and colleagues stated that the trend
in orthodontics is to eliminate both physical im-
*Registered trademark of Align Technology, San Jose, CA; www.
aligntech.com.
**Carestream Dental, Atlanta, GA; www.carestreamdental.com.
***Align Technology, Inc., San Jose, CA; www.aligntech.com.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
JERROLD, SCHULTE, ISAACS HENRY
pressions and the corresponding plaster casts alto-
gether.
24
Using dry skulls, they compared caliper
measurements of the actual teeth with those ob-
tained from a Carestream** CBCT and a Cadent
iTero*** intraoral scanner. The CBCT measure-
ments agreed with the actual measurements with-
in a range of .88mm-.99mm (except for the bucco-
lingual dimension of the lower anterior teeth,
which was .65mm), while the scanned measure-
ments agreed within .92mm-.99mm. The conclu-
sion was that both CBCT and the digital scanner
produced results that were “interchangeable” with
manual measurements.
Photographs
Callahan brought up the issue that serves as
the basis of this article by stating that in contem-
porary practice, a preliminary diagnosis and treat-
ment plan are often based on the clinical evaluation
supplemented only by photographs and radio-
graphs.
7
He questioned whether study models
would add any significant diagnostic data that
would result in a change of the provisional diag-
nosis or treatment plan.
Color photography can distinguish between
healthy and diseased tissue and can identify such
pathological findings as “white patches, inflam-
mation, ulceration, burns, lacerations, carcinoma,
. . . enamel translucency, decay, erosion and abra-
sion, as well as cervical dentin exposure and scle-
rosis, . . . shade analysis . . . and bleaching,” along
with other observations that cannot be made from
plaster casts or 3D imaging.
25
The following photo
graphic findings should routinely be recorded for
medicolegal documentation, formulation of a di-
agnosis and treatment plan, and assessment of the treatment outcome. Healthy vs. diseased tissue: Documenting poor oral hygiene is a cardinal concern. Orthodontic treatment should not be initiated or continued when hygiene is poor, since inflammation can rap-
idly lead to periodontal breakdown.
dex, averaging 3.75mm, and various occlusal indi-
ces (Peer Assessment Rating; Index of Complexi-
ty, Outcome, and Need; and ABO), averaging about 2mm each. In a clinical context, replacing plaster casts with digital models resulted in a change in diagnosis roughly 13% of the time, but changes in the actual treatment plan occurred in only 6% of the cases studied.
Arch-length analysis is one of the most com-
mon assessments performed with plaster casts. Leifert and colleagues found a difference in space analysis of less than .5mm between plaster casts and digital models, concluding once more that there was no clinical significance to the results.
22
One problem with their study was the use of a traditional brass-wire method to evaluate the avail-
able arch length; it was unclear whether the arch perimeter was measured at the center, off-center to the buccal side, or off-center to the lingual side of the ridge. Because opinions of where the teeth should sit in each arch may vary, this measurement could certainly make a clinical difference. Still, if the methodology of the analysis is consistent, it will not matter whether the measurement is made on plaster or on a digital image.
In a report by Mok and colleagues, 24% of
plaster casts could not be used because of damage, leading to the conclusion that—all else being equal—digital models are superior to plaster.
13
Therefore, if models are being saved for medico-
legal reasons, the use of plaster casts would not guarantee the permanence of those records. Mok and colleagues found that “2-dimensional imaging can be used as an alternative to casts in the assess-
ment of malocclusion and orthodontic treatment need.” It is interesting that they referred to digital models as 2D rather than 3D. This is because any individual view of a scanned model is a 2D im-
age—the same as a photograph. The only advan-
tage of 3D digital imagery is that all three dimen-
sions can be viewed by looking at multiple 2D images, one at a time. Magness admonished that while 3D views are “intriguing, valuable and in-
forming, orthodontists shouldn’t abandon 2-D views” as a format for recording data.
23
Akyalcin and colleagues stated that the trend
in orthodontics is to eliminate both physical im-
*Registered trademark of Align Technology, San Jose, CA; www.
aligntech.com.
**Carestream Dental, Atlanta, GA; www.carestreamdental.com.
***Align Technology, Inc., San Jose, CA; www.aligntech.com.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
88 JCO/FEBRUARY 2019
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
Amount of attached gingiva: Used to assess the
patient’s periodontal biotype.
Transition between keratinized and nonkeratinized
gingiva: Aids in determining where to place tem-
porary anchorage devices.
Enamel characteristics (mottling, stains, hypopla -
sia, chips, fractures, hypocalcification, fluorosis,
tetracycline stains): Helps select teeth to be bond-
ed and the medium to be used; documents debond-
ing damage and any negative sequelae.
Attrition, abrasion, erosion: Demonstrates that
any damage was not caused by the practitioner;
reveals preexisting white-spot lesions.
Reddy and colleagues noted that intraoral
photography “often represents the best method to
collect and preserve evidence in day-to-day prac-
tice, institutional cases and forensic cases.”
26
They
added that dental photography is an important
risk-management tool, and that any legally threat-
ening clinical situation should be documented,
dated, and preserved. Appropriate use of photo-
graphic principles, camera systems, and computer
software programs can enhance diagnosis and
treatment planning; enable better assessment of the
efficacy and results of treatment; and provide a
superior method of communicating with patients,
colleagues, and third parties.
Ahmad emphasized the need for a photo-
graphic consent form to address both permission
for treatment and patient privacy concerns.
27
The
following simple paragraph is one that Dr. Jerrold
has recommended to practitioners over the years
and can be integrated into any existing office form:
“Like all health-care services, my doctor may have
to consult with other health-care professionals con-
cerning my treatment. This will often involve send-
ing my clinical information over the Internet. Per-
mission is hereby granted to use the Internet to
effectively exchange medical and dental information
about me/my child only as it relates to providing my/
my child’s orthodontic treatment. In addition, I give
my permission for photos, x-rays, models, and clin-
ically relevant data of me/my child to be used in
scientific publications and/or presentations, for pur-
poses of maintaining licensure or specialty certifi-
cation, or for complying with duly authorized ad-
ministrative requests and for no other purpose.”
Verbal explanations to patients regarding
their treatment can sometimes be confusing or even
daunting.
27
A photographic portfolio of case stud-
ies is useful for both patient education and practice
marketing because it illustrates typical diagnoses,
treatments, outcomes, and assessments. A portfolio
also acts as a motivating factor in convincing pa-
tients to accept the recommended treatment.
To be viable and reliable, photographic re-
cords must meet a certain quality standard. Sandler
and colleagues noted that clinically acceptable
photographs can be fully and accurately assessed
from the outset, thus anticipating any potential
problems; can help determine the need for subse-
quent extractions or supplemental anchorage; can
assist in evaluating the progress of treatment and
in estimating the remaining time in appliances; can
record hard- and soft-tissue trauma, both acciden-
tal and non-accidental, and any other damage; and
can accurately preserve virtually every facet of
treatment for medicolegal purposes.
28
Not only
should pre- and post-treatment photographs be ob-
tained, but a routine photographic schedule should
be established. Photographs should be taken before
and after surgery, after retention, upon transfer of
a patient between practitioners, and at the comple-
tion of each treatment stage, as well as to document
positive or negative effects of specific treatment,
to document patient non-compliance, and to sup-
port requests for continued care from third-party
payers or requests for reimbursement.
29
In 2011, Sandler and colleagues surveyed 69
members of the Angle Society of Europe and found
that 35% took patient photographs themselves, 58%
had staff members routinely take their photos, and
7% used professional photographers.
28
The most
common extraoral errors in photographic technique
were related to poor camera positioning, including
improper adjustment for the patient’s height relative
to the photographer’s line of sight, inaccurate as-
sessment of Frankfort horizontal or natural head
position, and inappropriate soft-tissue positioning
(lack of lip repose). Other problems were closed
eyes and hair covering the ears. Intraoral errors
involved excessive saliva or bubbles in the field of
view, fog on the mirror, darkened buccal corridors,
insufficient tongue retraction, failure to capture the ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
Amount of attached gingiva: Used to assess the
patient’s periodontal biotype.
Transition between keratinized and nonkeratinized
gingiva: Aids in determining where to place tem-
porary anchorage devices.
Enamel characteristics (mottling, stains, hypopla -
sia, chips, fractures, hypocalcification, fluorosis,
tetracycline stains): Helps select teeth to be bond-
ed and the medium to be used; documents debond-
ing damage and any negative sequelae.
Attrition, abrasion, erosion: Demonstrates that
any damage was not caused by the practitioner;
reveals preexisting white-spot lesions.
Reddy and colleagues noted that intraoral
photography “often represents the best method to
collect and preserve evidence in day-to-day prac-
tice, institutional cases and forensic cases.”
26
They
added that dental photography is an important
risk-management tool, and that any legally threat-
ening clinical situation should be documented,
dated, and preserved. Appropriate use of photo-
graphic principles, camera systems, and computer
software programs can enhance diagnosis and
treatment planning; enable better assessment of the
efficacy and results of treatment; and provide a
superior method of communicating with patients,
colleagues, and third parties.
Ahmad emphasized the need for a photo-
graphic consent form to address both permission
for treatment and patient privacy concerns.
27
The
following simple paragraph is one that Dr. Jerrold
has recommended to practitioners over the years
and can be integrated into any existing office form:
“Like all health-care services, my doctor may have
to consult with other health-care professionals con-
cerning my treatment. This will often involve send-
ing my clinical information over the Internet. Per-
mission is hereby granted to use the Internet to
effectively exchange medical and dental information
about me/my child only as it relates to providing my/
my child’s orthodontic treatment. In addition, I give
my permission for photos, x-rays, models, and clin-
ically relevant data of me/my child to be used in
scientific publications and/or presentations, for pur-
poses of maintaining licensure or specialty certifi-
cation, or for complying with duly authorized ad-
ministrative requests and for no other purpose.”
Verbal explanations to patients regarding
their treatment can sometimes be confusing or even
daunting.
27
A photographic portfolio of case stud-
ies is useful for both patient education and practice
marketing because it illustrates typical diagnoses,
treatments, outcomes, and assessments. A portfolio
also acts as a motivating factor in convincing pa-
tients to accept the recommended treatment.
To be viable and reliable, photographic re-
cords must meet a certain quality standard. Sandler
and colleagues noted that clinically acceptable
photographs can be fully and accurately assessed
from the outset, thus anticipating any potential
problems; can help determine the need for subse-
quent extractions or supplemental anchorage; can
assist in evaluating the progress of treatment and
in estimating the remaining time in appliances; can
record hard- and soft-tissue trauma, both acciden-
tal and non-accidental, and any other damage; and
can accurately preserve virtually every facet of
treatment for medicolegal purposes.
28
Not only
should pre- and post-treatment photographs be ob-
tained, but a routine photographic schedule should
be established. Photographs should be taken before
and after surgery, after retention, upon transfer of
a patient between practitioners, and at the comple-
tion of each treatment stage, as well as to document
positive or negative effects of specific treatment,
to document patient non-compliance, and to sup-
port requests for continued care from third-party
payers or requests for reimbursement.
29
In 2011, Sandler and colleagues surveyed 69
members of the Angle Society of Europe and found
that 35% took patient photographs themselves, 58%
had staff members routinely take their photos, and
7% used professional photographers.
28
The most
common extraoral errors in photographic technique
were related to poor camera positioning, including
improper adjustment for the patient’s height relative
to the photographer’s line of sight, inaccurate as-
sessment of Frankfort horizontal or natural head
position, and inappropriate soft-tissue positioning
(lack of lip repose). Other problems were closed
eyes and hair covering the ears. Intraoral errors
involved excessive saliva or bubbles in the field of
view, fog on the mirror, darkened buccal corridors,
insufficient tongue retraction, failure to capture the ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
89VOLUME LIII NUMBER 2
JERROLD, SCHULTE, ISAACS HENRY
retaken. Sandler concluded that “intra-oral and
extra-oral photographs remain arguably the most
valuable clinical record that we can obtain from
our patients,” adding recommendations on how to
prevent photographic errors.
30
Almasoud and Bearn found 2D imaging to
be superior to 3D in evaluating a case with Little’s
Irregularity Index, because the vertical displace-
ment of the teeth hindered an accurate assessment
of the labiolingual discrepancies between contact
points.
31
They noted that photographs can provide
the same 2D views as in digital models. In this
study, the measurements made from photographs,
whether taken at 85°, 90°, or 95° to the model, were
within 1mm of the actual measurements of plaster
casts; measurements from photographs taken be-
tween 70° and 105° differed by no more than 2mm.
The ultimate determination was that clinical photo
graphs were both repeatable and reliable. The au-
thors added a few simple guidelines to improve the quality of photographic records: take frontal and lateral photographs of the teeth as perpendicular as possible to the point of focus, and show as much of both the labial and lingual surfaces of each tooth as possible in occlusal views. They suggested that a metal millimeter ruler crossing the arch should be used for calibration, although the ruler might need to be moved to recalibrate, depending on the relative location.
Ultimately, if photographs are to be an ac-
ceptable substitute for plaster or digital study mod-
els, the practitioner must be able to quantify vari-
ous dimensions with clinically acceptable precision. Orthodontists assess the severity of any malocclu-
sion by measuring the overjet, overbite, crowding, spacing, arch length, intermolar and intercanine width, and other parameters on models, using cal-
ipers or digital software. Photographs, because they are not 1:1, do not allow such measurements to be made precisely; rather, they can only be estimated. Mandall observed that the most difficult aspect of a malocclusion to measure from intraoral photo
graphy is the overjet, unless it is observed from a
lateral perpendicular view or from underneath.
32
Photographic scales created for the Ameri-
can Board of Forensic Odontology (ABFO) have now been used to provide geometric references for
distal margin of the first molar, obstruction by re-
tractors, poor focus, over- or underexposure, and overcropping of the field of view (taking the shot too close). The standard proposed for clinically adequate dental photography was whether more than 10% of the photographs needed to be retaken.
In a separate study, Sandler and colleagues
examined the quality of photographic records in a hospital clinic where only the orthodontist took the pictures, a private practice where only auxiliaries took the pictures, and a professional photogra-
pher’s office adjacent to an orthodontic practice.
30
Photographs were rated as good (no errors), accept-
able (some errors but still clinically useful), or un-
acceptable. An analysis of 50 extraoral photo-
graphs from each source indicated that the best were taken by the orthodontists, with 22 judged as good and 28 as acceptable. The auxiliaries fol-
lowed with 19 good and 31 acceptable photos. The professional photographer had the worst showing, with 15 pictures judged as good and 35 acceptable. No photographs from any source were considered unacceptable. Out of 50 intraoral photographs, the orthodontists again scored best with 16 good and 34 acceptable; the professional photographer was second with 19 good, 30 acceptable, and one un-
acceptable; and the auxiliaries fared the worst with three good, 44 acceptable, and three unacceptable.
The most common errors among orthodon-
tists in taking extraoral photos were poor head posture (tipped up or down) and poor focus. The professional photographer was more likely to take underexposed or poorly focused shots. Auxiliaries were found to display a multitude of errors in var-
ious techniques. In intraoral photography, the ma-
jor errors made by orthodontists were failure to capture the distal aspect of the first molar in buc-
cal views, underexposed shots, overcropped mirror shots, tipped occlusal planes, and excessive saliva bubbles. The professional photographer’s main shortcomings were overcropped mirror views and underexposed shots. The dental auxiliaries almost always missed the distal surface of the first molar, and they tended to underexpose their shots and to cant the occlusal planes. Regardless, all three groups performed within the standard, in that none had to have more than 10% of the photographs ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
JERROLD, SCHULTE, ISAACS HENRY
retaken. Sandler concluded that “intra-oral and
extra-oral photographs remain arguably the most
valuable clinical record that we can obtain from
our patients,” adding recommendations on how to
prevent photographic errors.
30
Almasoud and Bearn found 2D imaging to
be superior to 3D in evaluating a case with Little’s
Irregularity Index, because the vertical displace-
ment of the teeth hindered an accurate assessment
of the labiolingual discrepancies between contact
points.
31
They noted that photographs can provide
the same 2D views as in digital models. In this
study, the measurements made from photographs,
whether taken at 85°, 90°, or 95° to the model, were
within 1mm of the actual measurements of plaster
casts; measurements from photographs taken be-
tween 70° and 105° differed by no more than 2mm.
The ultimate determination was that clinical photo
graphs were both repeatable and reliable. The au-
thors added a few simple guidelines to improve the quality of photographic records: take frontal and lateral photographs of the teeth as perpendicular as possible to the point of focus, and show as much of both the labial and lingual surfaces of each tooth as possible in occlusal views. They suggested that a metal millimeter ruler crossing the arch should be used for calibration, although the ruler might need to be moved to recalibrate, depending on the relative location.
Ultimately, if photographs are to be an ac-
ceptable substitute for plaster or digital study mod-
els, the practitioner must be able to quantify vari-
ous dimensions with clinically acceptable precision. Orthodontists assess the severity of any malocclu-
sion by measuring the overjet, overbite, crowding, spacing, arch length, intermolar and intercanine width, and other parameters on models, using cal-
ipers or digital software. Photographs, because they are not 1:1, do not allow such measurements to be made precisely; rather, they can only be estimated. Mandall observed that the most difficult aspect of a malocclusion to measure from intraoral photo
graphy is the overjet, unless it is observed from a
lateral perpendicular view or from underneath.
32
Photographic scales created for the Ameri-
can Board of Forensic Odontology (ABFO) have now been used to provide geometric references for
distal margin of the first molar, obstruction by re-
tractors, poor focus, over- or underexposure, and overcropping of the field of view (taking the shot too close). The standard proposed for clinically adequate dental photography was whether more than 10% of the photographs needed to be retaken.
In a separate study, Sandler and colleagues
examined the quality of photographic records in a hospital clinic where only the orthodontist took the pictures, a private practice where only auxiliaries took the pictures, and a professional photogra-
pher’s office adjacent to an orthodontic practice.
30
Photographs were rated as good (no errors), accept-
able (some errors but still clinically useful), or un-
acceptable. An analysis of 50 extraoral photo-
graphs from each source indicated that the best were taken by the orthodontists, with 22 judged as good and 28 as acceptable. The auxiliaries fol-
lowed with 19 good and 31 acceptable photos. The professional photographer had the worst showing, with 15 pictures judged as good and 35 acceptable. No photographs from any source were considered unacceptable. Out of 50 intraoral photographs, the orthodontists again scored best with 16 good and 34 acceptable; the professional photographer was second with 19 good, 30 acceptable, and one un-
acceptable; and the auxiliaries fared the worst with three good, 44 acceptable, and three unacceptable.
The most common errors among orthodon-
tists in taking extraoral photos were poor head posture (tipped up or down) and poor focus. The professional photographer was more likely to take underexposed or poorly focused shots. Auxiliaries were found to display a multitude of errors in var-
ious techniques. In intraoral photography, the ma-
jor errors made by orthodontists were failure to capture the distal aspect of the first molar in buc-
cal views, underexposed shots, overcropped mirror shots, tipped occlusal planes, and excessive saliva bubbles. The professional photographer’s main shortcomings were overcropped mirror views and underexposed shots. The dental auxiliaries almost always missed the distal surface of the first molar, and they tended to underexpose their shots and to cant the occlusal planes. Regardless, all three groups performed within the standard, in that none had to have more than 10% of the photographs ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
90 JCO/FEBRUARY 2019
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
precise dental measurements that are accepted by
courts worldwide.
33
The accuracy of any such scale
is determined by comparing the distance from the
zero gradation and each subsequent gradation to
the nominal distance measured. The tolerance uni-
versally accepted for the ABFO is ±.1mm for every
1cm of distance from the focal point. The allow-
able tolerance for forensic photography scales is
.5mm. According to Tomita and Honda, because
humans can easily discern .5mm discrepancies
with the naked eye, a metal millimeter ruler is an
excellent intraoral scale for calibrating measure-
ments.
34
The same could not be said of a plastic
ruler, because temperature fluctuations in the out-
door environment could alter its dimensional sta-
bility. Whether a plastic ruler could be used in-
doors was not addressed by Tomita and Honda,
but it could be a reasonable alternative considering
the lack of temperature fluctuation in a clinical
orthodontic setting.
Finally, the issue of falsifying photographic
records by digital manipulation should be ad-
dressed. Madhan and Gayathri noted concerns
regarding the vulnerability of scientific literature
to digital forgery.
35
Similar concerns have been
expressed by various certifying boards, courts of
law, and third-party payers who depend on the va-
lidity of the records submitted to grant pre-
authorizations and continued payments for treat-
ment. What is not in dispute is the validity of initial
records acquired for diagnosis and treatment plan-
ning, since unaltered records are needed to make
appropriate treatment decisions. It remains possi-
ble, however, that an unethical practitioner could
alter the original records to hide diagnostic errors
leading to negative outcomes.
Practice Philosophy
Although the literature would seem to sup-
port the premise that photographs can be substi-
tuted for study models, whether plaster or digital,
this would be an oversimplification. For one thing,
it does not take into account the different philoso-
phies of orthodontic case presentation. In contem-
porary practice, there are two distinct approaches:
one-step and two-step.
In the one-step approach, a patient presents
to the office and a screening examination is per-
formed. Many practitioners will take a panoram-
ic radiograph at this time; some take photographs
and, on occasion, a cephalometric film. Treatment
recommendations are based mainly on the clini-
cal examination and the panoramic x-ray. The
patient’s questions are answered; financial agree-
ments follow; and upon acceptance of all other
administrative terms, in congruity with the pa-
tient’s expectations, a doctor-patient relationship
is established and the case moves forward. A
more detailed clinical exam is often performed
after case acceptance, and other orthodontic re-
cords may be acquired, including models, addi-
tional photographs, and a cephalogram (if not
already taken). If the case is straightforward and
the patient is cavity-free with good oral hygiene,
treatment can be started immediately. In the one-
step consultation practice, models are not usually
acquired for diagnosis and treatment planning,
but are sometimes obtained later for clinical and
administrative purposes. Burris noted that if the
diagnosis or treatment plan changes as a result of
any additional records, “this can often be present-
ed as enhanced care for the patient based on ad-
ditional information acquired.”
36
The second type of consultation is the two-
step approach, as described in detail by Moskow-
itz.
37
While the one-step approach “leads to more
annual patient treatment starts,” the traditional
protocol—involving comprehensive records at the
first appointment and a formal consultation at the
second—provides an atmosphere for more unstruc-
tured and unhurried discussions with the patient
or parent. This often leads to more realistic expec-
tations and allows contingency plans or potential
changes in strategy to be discussed prior to the
initiation of treatment. Approaches to borderline
cases can be outlined, and sentiments regarding
future extractions or orthognathic surgery, based
on clinically developing outcomes, can be assessed
before actually having to deal with such issues
during treatment. Moskowitz observed that “the
prime source of parent or patient dissatisfaction
can be traced to what was said or not during the
consultation process,” and that the two-step con-?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
precise dental measurements that are accepted by
courts worldwide.
33
The accuracy of any such scale
is determined by comparing the distance from the
zero gradation and each subsequent gradation to
the nominal distance measured. The tolerance uni-
versally accepted for the ABFO is ±.1mm for every
1cm of distance from the focal point. The allow-
able tolerance for forensic photography scales is
.5mm. According to Tomita and Honda, because
humans can easily discern .5mm discrepancies
with the naked eye, a metal millimeter ruler is an
excellent intraoral scale for calibrating measure-
ments.
34
The same could not be said of a plastic
ruler, because temperature fluctuations in the out-
door environment could alter its dimensional sta-
bility. Whether a plastic ruler could be used in-
doors was not addressed by Tomita and Honda,
but it could be a reasonable alternative considering
the lack of temperature fluctuation in a clinical
orthodontic setting.
Finally, the issue of falsifying photographic
records by digital manipulation should be ad-
dressed. Madhan and Gayathri noted concerns
regarding the vulnerability of scientific literature
to digital forgery.
35
Similar concerns have been
expressed by various certifying boards, courts of
law, and third-party payers who depend on the va-
lidity of the records submitted to grant pre-
authorizations and continued payments for treat-
ment. What is not in dispute is the validity of initial
records acquired for diagnosis and treatment plan-
ning, since unaltered records are needed to make
appropriate treatment decisions. It remains possi-
ble, however, that an unethical practitioner could
alter the original records to hide diagnostic errors
leading to negative outcomes.
Practice Philosophy
Although the literature would seem to sup-
port the premise that photographs can be substi-
tuted for study models, whether plaster or digital,
this would be an oversimplification. For one thing,
it does not take into account the different philoso-
phies of orthodontic case presentation. In contem-
porary practice, there are two distinct approaches:
one-step and two-step.
In the one-step approach, a patient presents
to the office and a screening examination is per-
formed. Many practitioners will take a panoram-
ic radiograph at this time; some take photographs
and, on occasion, a cephalometric film. Treatment
recommendations are based mainly on the clini-
cal examination and the panoramic x-ray. The
patient’s questions are answered; financial agree-
ments follow; and upon acceptance of all other
administrative terms, in congruity with the pa-
tient’s expectations, a doctor-patient relationship
is established and the case moves forward. A
more detailed clinical exam is often performed
after case acceptance, and other orthodontic re-
cords may be acquired, including models, addi-
tional photographs, and a cephalogram (if not
already taken). If the case is straightforward and
the patient is cavity-free with good oral hygiene,
treatment can be started immediately. In the one-
step consultation practice, models are not usually
acquired for diagnosis and treatment planning,
but are sometimes obtained later for clinical and
administrative purposes. Burris noted that if the
diagnosis or treatment plan changes as a result of
any additional records, “this can often be present-
ed as enhanced care for the patient based on ad-
ditional information acquired.”
36
The second type of consultation is the two-
step approach, as described in detail by Moskow-
itz.
37
While the one-step approach “leads to more
annual patient treatment starts,” the traditional
protocol—involving comprehensive records at the
first appointment and a formal consultation at the
second—provides an atmosphere for more unstruc-
tured and unhurried discussions with the patient
or parent. This often leads to more realistic expec-
tations and allows contingency plans or potential
changes in strategy to be discussed prior to the
initiation of treatment. Approaches to borderline
cases can be outlined, and sentiments regarding
future extractions or orthognathic surgery, based
on clinically developing outcomes, can be assessed
before actually having to deal with such issues
during treatment. Moskowitz observed that “the
prime source of parent or patient dissatisfaction
can be traced to what was said or not during the
consultation process,” and that the two-step con-?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
91VOLUME LIII NUMBER 2
JERROLD, SCHULTE, ISAACS HENRY
for plaster or digital models. We compared mea-
surements acquired directly from plaster casts
against those estimated using only photographs.
Materials and Methods
Five patients seeking orthodontic treatment
were enlisted in this clinical trial. Institutional Re-
view Board approval was not sought because the
photographs would be non-invasive and the ortho-
dontic records were routine. At each patient’s ini-
tial appointment, a comprehensive, detailed clini-
cal examination was performed by two research
associates. This was supplemented by 13 photo-
graphs (three extraoral and 10 intraoral), panoram-
ic and lateral cephalometric radiographs, and algi-
nate impressions for plaster study casts. No special
effort was made to obtain the photographs in any
manner different from the usual practice, but ab-
solutely no patient identifiers were used.
All photographs were taken with a Canon
Rebel T3† camera equipped with a macro EF
100mm USM lens and set at f/2.8 aperture,
sultation creates an environment for “more efforts
in patient education than in salesmanship.” Obvi-
ously, in the two-step practice, either plaster or
digital models are key patient-education and mar-
keting tools.
Because both philosophies are viable meth-
ods of diagnosis and treatment planning, both can
be deemed to be best practices that fall within the
standard of care. Each approach has its pluses and
minuses. Regardless, it is safe to conclude that in
the one-step practice, for the overwhelming major-
ity of patients, models of any type are superfluous
and can be replaced by good sets of high-quality
photographs.
Preliminary Clinical Study
We undertook a preliminary clinical investi-
gation to evaluate the best way to acquire adequate
diagnostic information using intraoral photography.
Our research was designed to address two factors:
how to take high-quality photographs, and wheth-
er the data gathered would fall within clinically
acceptable parameters to the extent that orthodon-
tists would be justified in substituting photographs
Fig. 1 Prototype cheek retractor‡ (A)
and occlusal mirror‡ (B) with built-in
rulers.
†Trademark of Canon USA, Melville, NY; www.usa.canon.com.
‡Orthopli Corp., Philadelphia, PA; www.orthopli.com.
B
A?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
JERROLD, SCHULTE, ISAACS HENRY
for plaster or digital models. We compared mea-
surements acquired directly from plaster casts
against those estimated using only photographs.
Materials and Methods
Five patients seeking orthodontic treatment
were enlisted in this clinical trial. Institutional Re-
view Board approval was not sought because the
photographs would be non-invasive and the ortho-
dontic records were routine. At each patient’s ini-
tial appointment, a comprehensive, detailed clini-
cal examination was performed by two research
associates. This was supplemented by 13 photo-
graphs (three extraoral and 10 intraoral), panoram-
ic and lateral cephalometric radiographs, and algi-
nate impressions for plaster study casts. No special
effort was made to obtain the photographs in any
manner different from the usual practice, but ab-
solutely no patient identifiers were used.
All photographs were taken with a Canon
Rebel T3† camera equipped with a macro EF
100mm USM lens and set at f/2.8 aperture,
sultation creates an environment for “more efforts
in patient education than in salesmanship.” Obvi-
ously, in the two-step practice, either plaster or
digital models are key patient-education and mar-
keting tools.
Because both philosophies are viable meth-
ods of diagnosis and treatment planning, both can
be deemed to be best practices that fall within the
standard of care. Each approach has its pluses and
minuses. Regardless, it is safe to conclude that in
the one-step practice, for the overwhelming major-
ity of patients, models of any type are superfluous
and can be replaced by good sets of high-quality
photographs.
Preliminary Clinical Study
We undertook a preliminary clinical investi-
gation to evaluate the best way to acquire adequate
diagnostic information using intraoral photography.
Our research was designed to address two factors:
how to take high-quality photographs, and wheth-
er the data gathered would fall within clinically
acceptable parameters to the extent that orthodon-
tists would be justified in substituting photographs
Fig. 1 Prototype cheek retractor‡ (A)
and occlusal mirror‡ (B) with built-in
rulers.
†Trademark of Canon USA, Melville, NY; www.usa.canon.com.
‡Orthopli Corp., Philadelphia, PA; www.orthopli.com.
B
A?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
92 JCO/FEBRUARY 2019
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
1/200-second shutter speed, and ISO 200 sensitiv-
ity. This basic 35mm single-lens reflex digital cam-
era is commonly used in the clinical setting. Direct
intraoral photographs were taken while the patient
held a prototype cheek retractor‡ with a built-in
millimetric ruler that had been calibrated to a met-
al millimeter ruler (Fig. 1A). The only additional
instruction was that the patient should be as close
to natural head position as possible, thus approxi-
mating Frankfort horizontal. Intraoral occlusal
photographs were taken using a prototype mirror,‡
with calibration provided by millimeter scales of
40mm and 20mm (Fig. 1B). The two scales were
located in the intermolar and intercanine regions of
the mirror, respectively, to account for significant
distortion from angulation discrepancies among the
occlusal plane, mirror, and camera position, as de-
scribed by Almasoud and Bearn
31
and Mandall.
32
For overjet measurement, a photograph was
taken perpendicular to Frankfort horizontal with
a metal millimeter ruler held parallel to the occlu-
sal plane, flush with the labial aspect of the most
lingual mandibular incisors (Fig. 2). The photo-
graph for evaluating anterior palatal hard- or
soft-tissue contact was taken at a 45-90° angle
from below the occlusal plane, using the prototype
mirror (Fig. 3). This allowed the clinician to assess
any contact between the palatal aspect of the max-
illary incisors and the labial aspect of the mandib-
ular incisors, indicating relative overjet or palatal
impingement. The next image was taken facing the
patient, with cheek retractors in place and the
mouth slightly opened to reveal the entire length
of the lower incisor crowns (Fig. 4). To measure
the clinical crown height, an intraoral ruler was
placed so that one edge was flush with the incisal
edge of a lower incisor. This also allowed the cli-
nician to calculate the overbite in millimeters once
the patient was allowed to close in occlusion. The
remaining two images were taken from the right
and left sides, perpendicular to Frankfort horizon-
tal, while the patient bit on a wooden tongue de-
pressor, thus allowing assessment of the right and
left curves of Spee (Fig. 5).
Of the 50 images taken for this study, four
would have needed to be retaken in clinical prac-
tice. One mirror shot of the lower anterior teeth
was blurry. In another photo, the ruler on the mir-
ror slightly overlapped some aspects of the lower
anterior dentition. Two intraoral photographs did
not fully reveal the first-molar relationships. This
retake ratio was 8%, within the accepted 10% stan-
dard for intraoral photography.
30
Plaster study casts were prepared from algi-
nate impressions taken at the initial appointments.
A digital caliper‡ and standard 6" plastic ruler
were used by Dr. Jerrold to acquire the same data
sets that would be measured from the photographs.
The cast measurements were made before the re-
sults of the study evaluation sheets were tabulated.
All 50 intraoral photographs were evaluated
by eight orthodontic residents and five faculty
Fig. 2 Metal ruler used for overjet evaluation.
Fig. 3 Measuring anterior palatal hard- or soft-tissue
contact.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
1/200-second shutter speed, and ISO 200 sensitiv-
ity. This basic 35mm single-lens reflex digital cam-
era is commonly used in the clinical setting. Direct
intraoral photographs were taken while the patient
held a prototype cheek retractor‡ with a built-in
millimetric ruler that had been calibrated to a met-
al millimeter ruler (Fig. 1A). The only additional
instruction was that the patient should be as close
to natural head position as possible, thus approxi-
mating Frankfort horizontal. Intraoral occlusal
photographs were taken using a prototype mirror,‡
with calibration provided by millimeter scales of
40mm and 20mm (Fig. 1B). The two scales were
located in the intermolar and intercanine regions of
the mirror, respectively, to account for significant
distortion from angulation discrepancies among the
occlusal plane, mirror, and camera position, as de-
scribed by Almasoud and Bearn
31
and Mandall.
32
For overjet measurement, a photograph was
taken perpendicular to Frankfort horizontal with
a metal millimeter ruler held parallel to the occlu-
sal plane, flush with the labial aspect of the most
lingual mandibular incisors (Fig. 2). The photo-
graph for evaluating anterior palatal hard- or
soft-tissue contact was taken at a 45-90° angle
from below the occlusal plane, using the prototype
mirror (Fig. 3). This allowed the clinician to assess
any contact between the palatal aspect of the max-
illary incisors and the labial aspect of the mandib-
ular incisors, indicating relative overjet or palatal
impingement. The next image was taken facing the
patient, with cheek retractors in place and the
mouth slightly opened to reveal the entire length
of the lower incisor crowns (Fig. 4). To measure
the clinical crown height, an intraoral ruler was
placed so that one edge was flush with the incisal
edge of a lower incisor. This also allowed the cli-
nician to calculate the overbite in millimeters once
the patient was allowed to close in occlusion. The
remaining two images were taken from the right
and left sides, perpendicular to Frankfort horizon-
tal, while the patient bit on a wooden tongue de-
pressor, thus allowing assessment of the right and
left curves of Spee (Fig. 5).
Of the 50 images taken for this study, four
would have needed to be retaken in clinical prac-
tice. One mirror shot of the lower anterior teeth
was blurry. In another photo, the ruler on the mir-
ror slightly overlapped some aspects of the lower
anterior dentition. Two intraoral photographs did
not fully reveal the first-molar relationships. This
retake ratio was 8%, within the accepted 10% stan-
dard for intraoral photography.
30
Plaster study casts were prepared from algi-
nate impressions taken at the initial appointments.
A digital caliper‡ and standard 6" plastic ruler
were used by Dr. Jerrold to acquire the same data
sets that would be measured from the photographs.
The cast measurements were made before the re-
sults of the study evaluation sheets were tabulated.
All 50 intraoral photographs were evaluated
by eight orthodontic residents and five faculty
Fig. 2 Metal ruler used for overjet evaluation.
Fig. 3 Measuring anterior palatal hard- or soft-tissue
contact.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
93VOLUME LIII NUMBER 2
JERROLD, SCHULTE, ISAACS HENRY
this study was to determine whether the calibration
scales in the photographs could be used to measure
dimensions to the level of clinical acceptability.
The exercise took 30-45 minutes per exam-
iner to record all five cases. With 13 clinicians
each recording 12 measurements on each of five
patients, a total of 780 measurements were collect-
ed. Descriptive, as opposed to inferential, statistics
were deemed to be the most appropriate way to
analyze the results and determine clinical signifi-
cance. Therefore, the mean, median, and mode of
each recording were compared with the actual
measurement from the plaster cast.
Results
Overbite: The mean overbite measurements ob-
tained from the photographs alone were within
1mm of the actual cast measurements in all five
cases; in two of the cases, they were within .5mm
of the actual measurements (Table 1).
Curve of Spee: In the more routine cases (1, 4, and
5) and on the right sides of the other two cases, the
examiners were amazingly accurate, within .5mm
of the actual measurements. Case 2 was problem-
atic because of an anterior open bite, which creat-
ed a slight posterior curve of Spee but a reverse
curve in the anterior area. Case 3 had an ankylosed
lower left second deciduous molar and a missing
lower left first deciduous molar, making it more
difficult to judge where to measure the deepest
point on the occlusal surface.
members. The residents’ clinical dental experience
ranged from two to 19 years, with a mean of six
years. The faculty’s ranged from seven to 39 years,
with a mean of 24 years as an orthodontist. Each
examiner was given a composite photo page of
every patient’s 10 intraoral views. In addition to
the millimetric scales captured by the photographs,
each participant was given a 6" plastic ruler to use
for calibration purposes, along with instructions
and an evaluation sheet (Fig. 6).
The examiners were instructed to measure
10mm on the calibration scale of each photograph
with the plastic ruler and to note any difference.
For example, if 12mm on the calibration scale mea-
sured 10mm on the ruler, the examiner could as-
sume a 20% distortion factor—in other words,
every millimeter of crowding on the photograph
would be equivalent to .8mm of true crowding. The
examiners were told that the calibration scale on
each mirror, cheek retractor, or lip retractor could
be different—smaller or larger depending on dis-
tance and angulation—and that they should not
assume the same distortion factor in every photo-
graph. All measurements were to be rounded to
the nearest .5mm.
Several participants revealed that they made
some measurements by “eyeballing,” using the cal-
ibration scale in the photograph as a guide. We did
not ask which measurements were obtained by rul-
er or by visual inspection alone, since the point of
‡Orthopli Corp., Philadelphia, PA; www.orthopli.com.
Fig. 4 Evaluation of overbite.
Fig. 5 Measuring depth of curve of Spee.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
JERROLD, SCHULTE, ISAACS HENRY
this study was to determine whether the calibration
scales in the photographs could be used to measure
dimensions to the level of clinical acceptability.
The exercise took 30-45 minutes per exam-
iner to record all five cases. With 13 clinicians
each recording 12 measurements on each of five
patients, a total of 780 measurements were collect-
ed. Descriptive, as opposed to inferential, statistics
were deemed to be the most appropriate way to
analyze the results and determine clinical signifi-
cance. Therefore, the mean, median, and mode of
each recording were compared with the actual
measurement from the plaster cast.
Results
Overbite: The mean overbite measurements ob-
tained from the photographs alone were within
1mm of the actual cast measurements in all five
cases; in two of the cases, they were within .5mm
of the actual measurements (Table 1).
Curve of Spee: In the more routine cases (1, 4, and
5) and on the right sides of the other two cases, the
examiners were amazingly accurate, within .5mm
of the actual measurements. Case 2 was problem-
atic because of an anterior open bite, which creat-
ed a slight posterior curve of Spee but a reverse
curve in the anterior area. Case 3 had an ankylosed
lower left second deciduous molar and a missing
lower left first deciduous molar, making it more
difficult to judge where to measure the deepest
point on the occlusal surface.
members. The residents’ clinical dental experience
ranged from two to 19 years, with a mean of six
years. The faculty’s ranged from seven to 39 years,
with a mean of 24 years as an orthodontist. Each
examiner was given a composite photo page of
every patient’s 10 intraoral views. In addition to
the millimetric scales captured by the photographs,
each participant was given a 6" plastic ruler to use
for calibration purposes, along with instructions
and an evaluation sheet (Fig. 6).
The examiners were instructed to measure
10mm on the calibration scale of each photograph
with the plastic ruler and to note any difference.
For example, if 12mm on the calibration scale mea-
sured 10mm on the ruler, the examiner could as-
sume a 20% distortion factor—in other words,
every millimeter of crowding on the photograph
would be equivalent to .8mm of true crowding. The
examiners were told that the calibration scale on
each mirror, cheek retractor, or lip retractor could
be different—smaller or larger depending on dis-
tance and angulation—and that they should not
assume the same distortion factor in every photo-
graph. All measurements were to be rounded to
the nearest .5mm.
Several participants revealed that they made
some measurements by “eyeballing,” using the cal-
ibration scale in the photograph as a guide. We did
not ask which measurements were obtained by rul-
er or by visual inspection alone, since the point of
‡Orthopli Corp., Philadelphia, PA; www.orthopli.com.
Fig. 4 Evaluation of overbite.
Fig. 5 Measuring depth of curve of Spee.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
94 JCO/FEBRUARY 2019
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
Upper-arch crowding: In all five cases, the exam-
iners’ average findings were within 1mm of the
actual amounts.
Lower-arch crowding: In three of the five cases,
the examiners were within 1mm of the actual mea-
surements. In Case 1, one examiner judged the
crowding to be 3mm more than it was; the remain-
der of the evaluators were more consistent, how-
ever, with the median and the mode both falling
within 1mm of actual. In Case 4, 60% of the ex-
aminers measured the crowding within 1mm,
while the others were within 2mm.
Overjet: In three of the five cases, the clinicians
were within .5mm of the actual measurements; in
one case, they were within 1mm; and in the last case,
they were within 1.5mm. We discovered that it was
misleading not to place the calibration tool on the
tooth with the greatest horizontal discrepancy.
Canine classification: Of the 10 total evaluations
(five cases, each with a right and left canine rela-
tionship), eight were in total agreement with the
baseline assessment of the casts (Table 2). In Case
5, 11 of the 13 examiners agreed, but in Case 3,
only four of 12 agreed. Upon reviewing the casts
for Case 3, it was found that the left canines were
end-on, cusp tip to cusp tip. Although the instruc-
tions stated that the classification should not
change until there was more than a half-cusp dif-
ference from the normal position, apparently eight
of the 12 examiners believed that an edge-to-edge
relationship qualified as a change in classification.
Molar classification: Of the 10 evaluations, five
were in total agreement with the baseline assess-
ment, while the other five classifications averaged
85% agreement. In Case 2, the right molar was
thought by two of the 13 evaluators to be in “super-
Class I.” In Case 3, two of the examiners found the
right molar to be edge-to-edge (but with no more
than a half-cusp variance). In Case 4, the upper left
molar had been restored with a crown smaller than
the original tooth’s, leading two examiners to judge
it as more edge-to-edge. Finally, in Case 5, the
molars could not be well visualized on the photo-
graph, which is why two examiners did not enter
Fig. 6 Sheet used by examiners to evaluate photos.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
Upper-arch crowding: In all five cases, the exam-
iners’ average findings were within 1mm of the
actual amounts.
Lower-arch crowding: In three of the five cases,
the examiners were within 1mm of the actual mea-
surements. In Case 1, one examiner judged the
crowding to be 3mm more than it was; the remain-
der of the evaluators were more consistent, how-
ever, with the median and the mode both falling
within 1mm of actual. In Case 4, 60% of the ex-
aminers measured the crowding within 1mm,
while the others were within 2mm.
Overjet: In three of the five cases, the clinicians
were within .5mm of the actual measurements; in
one case, they were within 1mm; and in the last case,
they were within 1.5mm. We discovered that it was
misleading not to place the calibration tool on the
tooth with the greatest horizontal discrepancy.
Canine classification: Of the 10 total evaluations
(five cases, each with a right and left canine rela-
tionship), eight were in total agreement with the
baseline assessment of the casts (Table 2). In Case
5, 11 of the 13 examiners agreed, but in Case 3,
only four of 12 agreed. Upon reviewing the casts
for Case 3, it was found that the left canines were
end-on, cusp tip to cusp tip. Although the instruc-
tions stated that the classification should not
change until there was more than a half-cusp dif-
ference from the normal position, apparently eight
of the 12 examiners believed that an edge-to-edge
relationship qualified as a change in classification.
Molar classification: Of the 10 evaluations, five
were in total agreement with the baseline assess-
ment, while the other five classifications averaged
85% agreement. In Case 2, the right molar was
thought by two of the 13 evaluators to be in “super-
Class I.” In Case 3, two of the examiners found the
right molar to be edge-to-edge (but with no more
than a half-cusp variance). In Case 4, the upper left
molar had been restored with a crown smaller than
the original tooth’s, leading two examiners to judge
it as more edge-to-edge. Finally, in Case 5, the
molars could not be well visualized on the photo-
graph, which is why two examiners did not enter
Fig. 6 Sheet used by examiners to evaluate photos.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
95VOLUME LIII NUMBER 2
JERROLD, SCHULTE, ISAACS HENRY
classifications are more problematic. They can be
accurately evaluated from photographs, but unless
clinicians can agree on what constitutes a Class I
vs. a Class II or Class III relationship, the point of
measuring the relationship is moot. Because of
differences in training and experience, every doc-
tor has acquired an individual clinical basis for
making such determinations. We recommend some
form of calibration training to address the situation
in each practice.
The same issues apply to analysis of the
curve of Spee. Many children present in various
stages of the mixed dentition with missing teeth.
Many adults present with missing teeth due to the
ravages of life. Either of these clinical scenarios
creates a subjective factor in trying to define the
depth of a curve. The problem lies not in the abil-
ity to accurately measure clinical findings, but in
determining the points from which the measure-
ments should be made and then calibrating practi-
tioners to ensure that everyone is measuring the
same thing.
For patients with either craniofacial anoma-
lies or dentofacial deformities (particularly Class
III cases), we recommend that models be acquired
along with photographs. These cases often place a
greater priority on anatomical considerations, in-
volving the construction of a variety of removable
appliances and possible surgical intervention, all
of which is more easily evaluated with models. If
model surgery or surgical splints are required, then
models become a necessity.
Significant anteroposterior discrepancies are
also somewhat problematic, particularly in Class III
patients. Because the human dentition is contained
in the form of an arch, the anterior portion is nar-
rower than the posterior portion. In a neutral or
Class I occlusal relationship, the transverse relation-
ship is considered normal when the posterior trans-
verse dimension is slightly wider in the maxilla than
in the mandible. As the skeletal relationship chang-
es in the AP direction, this transverse relationship
also changes. In a Class III case, the mandible be-
comes more anterior to the maxilla. The wider pos-
terior transverse dimension of the lower molars is
now related differently to the more narrow trans-
verse dimension of the upper premolars, resulting
an evaluation and two others disagreed with the
rest of the group.
Lower anterior palatal contact: All 13 examiners
were in 100% agreement with the baseline assess-
ment of three cases. In Case 1, three of the 13
noted palatal impingement. When the casts were
reexamined, it was discovered that the lower right
lateral incisor was contacting the upper right lat-
eral incisor directly at the junction of the tooth and
the gingival margin, justifying that decision. In
Case 5, upon reexamining the casts, three of the
lower anterior teeth were contacting their antago-
nists on the lingual, but the lower left lateral inci-
sor was actually touching soft tissue.
Posterior crossbite: Two cases were in 100%
agreement. In Case 4, 12 of the 13 examiners agreed
that there was no crossbite. On reexamination of
the casts, the right molar transverse relationship was
deemed to be “tight,” accounting for the discrepan-
cy. In Case 5, the molars could not be fully visual-
ized on the photographs, so that two examiners did
not express an opinion and one differed from the
remaining 10. Case 3 showed the greatest disparity,
with three of 13 examiners finding a crossbite.
Upon review, the right molars were found to be in
a transverse cusp-to-cusp relationship.
Discussion
Our first and most obvious conclusion is the
need to take high-quality photographs for diagnos-
tic purposes. No attempt was made to ensure that
the photographs used in this study would be better
than those acquired in the course of routine ortho-
dontic practice. It became readily apparent that
good photographs can be substituted for good
study models, good photographs are better than
bad models, and bad photographs are a bad substi-
tute for either good or bad models.
In routine cases, the overbite, overjet, upper
and lower anterior crowding, and palatal soft-tissue
contact could all be measured from photographs
within a clinically acceptable 1mm. Of the minori-
ty of measurements that did not meet this standard,
50% were within 1.5mm, and the remaining 50%
within 2mm of the actual measurements.
Posterior crossbites and canine and molar ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
JERROLD, SCHULTE, ISAACS HENRY
classifications are more problematic. They can be
accurately evaluated from photographs, but unless
clinicians can agree on what constitutes a Class I
vs. a Class II or Class III relationship, the point of
measuring the relationship is moot. Because of
differences in training and experience, every doc-
tor has acquired an individual clinical basis for
making such determinations. We recommend some
form of calibration training to address the situation
in each practice.
The same issues apply to analysis of the
curve of Spee. Many children present in various
stages of the mixed dentition with missing teeth.
Many adults present with missing teeth due to the
ravages of life. Either of these clinical scenarios
creates a subjective factor in trying to define the
depth of a curve. The problem lies not in the abil-
ity to accurately measure clinical findings, but in
determining the points from which the measure-
ments should be made and then calibrating practi-
tioners to ensure that everyone is measuring the
same thing.
For patients with either craniofacial anoma-
lies or dentofacial deformities (particularly Class
III cases), we recommend that models be acquired
along with photographs. These cases often place a
greater priority on anatomical considerations, in-
volving the construction of a variety of removable
appliances and possible surgical intervention, all
of which is more easily evaluated with models. If
model surgery or surgical splints are required, then
models become a necessity.
Significant anteroposterior discrepancies are
also somewhat problematic, particularly in Class III
patients. Because the human dentition is contained
in the form of an arch, the anterior portion is nar-
rower than the posterior portion. In a neutral or
Class I occlusal relationship, the transverse relation-
ship is considered normal when the posterior trans-
verse dimension is slightly wider in the maxilla than
in the mandible. As the skeletal relationship chang-
es in the AP direction, this transverse relationship
also changes. In a Class III case, the mandible be-
comes more anterior to the maxilla. The wider pos-
terior transverse dimension of the lower molars is
now related differently to the more narrow trans-
verse dimension of the upper premolars, resulting
an evaluation and two others disagreed with the
rest of the group.
Lower anterior palatal contact: All 13 examiners
were in 100% agreement with the baseline assess-
ment of three cases. In Case 1, three of the 13
noted palatal impingement. When the casts were
reexamined, it was discovered that the lower right
lateral incisor was contacting the upper right lat-
eral incisor directly at the junction of the tooth and
the gingival margin, justifying that decision. In
Case 5, upon reexamining the casts, three of the
lower anterior teeth were contacting their antago-
nists on the lingual, but the lower left lateral inci-
sor was actually touching soft tissue.
Posterior crossbite: Two cases were in 100%
agreement. In Case 4, 12 of the 13 examiners agreed
that there was no crossbite. On reexamination of
the casts, the right molar transverse relationship was
deemed to be “tight,” accounting for the discrepan-
cy. In Case 5, the molars could not be fully visual-
ized on the photographs, so that two examiners did
not express an opinion and one differed from the
remaining 10. Case 3 showed the greatest disparity,
with three of 13 examiners finding a crossbite.
Upon review, the right molars were found to be in
a transverse cusp-to-cusp relationship.
Discussion
Our first and most obvious conclusion is the
need to take high-quality photographs for diagnos-
tic purposes. No attempt was made to ensure that
the photographs used in this study would be better
than those acquired in the course of routine ortho-
dontic practice. It became readily apparent that
good photographs can be substituted for good
study models, good photographs are better than
bad models, and bad photographs are a bad substi-
tute for either good or bad models.
In routine cases, the overbite, overjet, upper
and lower anterior crowding, and palatal soft-tissue
contact could all be measured from photographs
within a clinically acceptable 1mm. Of the minori-
ty of measurements that did not meet this standard,
50% were within 1.5mm, and the remaining 50%
within 2mm of the actual measurements.
Posterior crossbites and canine and molar ?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
96 JCO/FEBRUARY 2019
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
in a posterior crossbite. If a set of models were
hand-positioned back into a neutral Class I relation-
ship, the crossbite might disappear. This is called a
relative transverse discrepancy because of the AP
differential of the jaws to each other, rather than the
absolute transverse differential. The degree of this
discrepancy can only be visualized through model
repositioning, either plaster or digital. The same
cannot be said of the vast majority of Class II mal-
occlusions, in which the patient can posture the
mandible forward and thus allow the relative trans-
verse discrepancy to be observed (and photo-
graphed). In summary, we recommend that models
be obtained in a Class III case exhibiting any degree
of transverse discrepancy, where the patient cannot
be positioned edge-to-edge anteriorly and the pos-
terior transverse relationship cannot be adequately
visualized. Most other cases of any classification
can be adequately documented through photogra-
phy. This should not be problematic in most prac-
tices, unless the patient demographic is skewed
toward Class III malocclusions.
If photographs can provide documentation of
certain clinical conditions that models cannot pro-
vide, there is other information that models can
provide but photographs cannot. The classic exam-
ple is that with models, plaster or digital, one can
figuratively stand on the patient’s tongue and look
around the mouth from the inside when the teeth
are in occlusion. Is it necessary, however, to see
this view? Practically speaking, it offers little ad-
ditional information that would significantly influ-
ence the diagnosis or treatment plan of any given
case. It may provide details regarding specific oc-
clusal interferences that could contribute to a func-
tional shift, but even so, it would have a negligible
effect on the treatment plan. It may also provide a
definitive answer to the question of whether there
is actual contact of the lower anterior teeth with
the palatal soft tissue in an equivocal case. In oth-
er words, while there may be some slight diagnos-
tic advantage to acquiring models, there is little
clinical advantage regarding the treatment plan or
mechanics to be employed.
Some orthodontists may feel more comfort-
able in having a set of models to provide a lingual/
palatal perspective with the teeth in occlusion.
That would be important, however, only if the
models were actually used for this purpose. To take
models and use them only after the diagnosis and
treatment plan have been established and treatment
initiated is not a reason for acquiring them in the
first place.
From a patient-management perspective, tak-
ing plaster or digital impressions for models rang-
es from mildly uncomfortable to downright tortur-
ous. Many patients exhibit a hyperactive gag reflex,
which can adversely affect the doctor-patient rela-
tionship—assuming the doctor is the one taking
the impression. That more than 60% of practi-
TABLE 1
MEAN PHOTOGRAPHIC VS. ACTUAL CAST MEASUREMENTS
Case 1 Case 2 Case 3 Case 4 Case 5
Photos Cast Photos Cast Photos Cast Photos Cast Photos Cast
Ov
erbite/Open bite
4.5mm 5.5mm 1.6mm 2.5mm 6.9mm 6.0mm 2.2mm 2.5mm 6.0mm 5.5mm
Right cur
ve of Spee
1.7mm 2.0mm 0.9mm 1.0mm 2.4mm 3.0mm 0.5mm 0.5mm 2.8mm 3.0mm
Left cur
ve of Spee
1.5mm 1.0mm −0.6mm 1.0mm 2.5mm 4.0mm 1.2mm 1.0mm 2.6mm 3.0mm
Upper-ar
ch crowding
2.3mm 1.5mm 1.6mm 2.5mm 5.0mm 4.0mm 1.5mm 1.0mm 3.6mm 3.0mm
Lower-ar
ch crowding
4.9mm 6.0mm 2.7mm 3.5mm 2.4mm 2.0mm 2.9mm 4.5mm 2.6mm 2.0mm
Ov
erjet
5.2mm 5.5mm 3.1mm 3.5mm 3.0mm 4.0mm 4.1mm 4.0mm 3.8mm 5.0mm?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
in a posterior crossbite. If a set of models were
hand-positioned back into a neutral Class I relation-
ship, the crossbite might disappear. This is called a
relative transverse discrepancy because of the AP
differential of the jaws to each other, rather than the
absolute transverse differential. The degree of this
discrepancy can only be visualized through model
repositioning, either plaster or digital. The same
cannot be said of the vast majority of Class II mal-
occlusions, in which the patient can posture the
mandible forward and thus allow the relative trans-
verse discrepancy to be observed (and photo-
graphed). In summary, we recommend that models
be obtained in a Class III case exhibiting any degree
of transverse discrepancy, where the patient cannot
be positioned edge-to-edge anteriorly and the pos-
terior transverse relationship cannot be adequately
visualized. Most other cases of any classification
can be adequately documented through photogra-
phy. This should not be problematic in most prac-
tices, unless the patient demographic is skewed
toward Class III malocclusions.
If photographs can provide documentation of
certain clinical conditions that models cannot pro-
vide, there is other information that models can
provide but photographs cannot. The classic exam-
ple is that with models, plaster or digital, one can
figuratively stand on the patient’s tongue and look
around the mouth from the inside when the teeth
are in occlusion. Is it necessary, however, to see
this view? Practically speaking, it offers little ad-
ditional information that would significantly influ-
ence the diagnosis or treatment plan of any given
case. It may provide details regarding specific oc-
clusal interferences that could contribute to a func-
tional shift, but even so, it would have a negligible
effect on the treatment plan. It may also provide a
definitive answer to the question of whether there
is actual contact of the lower anterior teeth with
the palatal soft tissue in an equivocal case. In oth-
er words, while there may be some slight diagnos-
tic advantage to acquiring models, there is little
clinical advantage regarding the treatment plan or
mechanics to be employed.
Some orthodontists may feel more comfort-
able in having a set of models to provide a lingual/
palatal perspective with the teeth in occlusion.
That would be important, however, only if the
models were actually used for this purpose. To take
models and use them only after the diagnosis and
treatment plan have been established and treatment
initiated is not a reason for acquiring them in the
first place.
From a patient-management perspective, tak-
ing plaster or digital impressions for models rang-
es from mildly uncomfortable to downright tortur-
ous. Many patients exhibit a hyperactive gag reflex,
which can adversely affect the doctor-patient rela-
tionship—assuming the doctor is the one taking
the impression. That more than 60% of practi-
TABLE 1
MEAN PHOTOGRAPHIC VS. ACTUAL CAST MEASUREMENTS
Case 1 Case 2 Case 3 Case 4 Case 5
Photos Cast Photos Cast Photos Cast Photos Cast Photos Cast
Ov
erbite/Open bite
4.5mm 5.5mm 1.6mm 2.5mm 6.9mm 6.0mm 2.2mm 2.5mm 6.0mm 5.5mm
Right cur
ve of Spee
1.7mm 2.0mm 0.9mm 1.0mm 2.4mm 3.0mm 0.5mm 0.5mm 2.8mm 3.0mm
Left cur
ve of Spee
1.5mm 1.0mm −0.6mm 1.0mm 2.5mm 4.0mm 1.2mm 1.0mm 2.6mm 3.0mm
Upper-ar
ch crowding
2.3mm 1.5mm 1.6mm 2.5mm 5.0mm 4.0mm 1.5mm 1.0mm 3.6mm 3.0mm
Lower-ar
ch crowding
4.9mm 6.0mm 2.7mm 3.5mm 2.4mm 2.0mm 2.9mm 4.5mm 2.6mm 2.0mm
Ov
erjet
5.2mm 5.5mm 3.1mm 3.5mm 3.0mm 4.0mm 4.1mm 4.0mm 3.8mm 5.0mm?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
97VOLUME LIII NUMBER 2
JERROLD, SCHULTE, ISAACS HENRY
tical significance, because these measurements
need to be more precise than the 1mm clinical
acceptability margin of error. Educational pro-
grams require study models for any number of
valid reasons. On the other hand, adequate docu-
mentation is possible with only intraoral photo-
graphs in routine lecture, educational, and
private-practice environments, especially after
some kind of calibration training.
From a clinical perspective, in the over-
whelming majority of cases and situations, there
does not seem to be any rational basis for not sub-
stituting photographs for plaster or digital models,
as long as high-quality photos can be acquired.
The following diagnostic criteria must be accurate-
ly determined, in millimeters:
1.
Canine and molar classification.
2. Anterior or posterior crossbite.
3. Depth of vertical overbite or amount of anterior
open bite. 4.
Palatal impingement by the lower anterior den-
tition. 5.
Horizontal overbite or overjet.
6. Depth of the curve of Spee.
7. Degree of crowding or spacing within each arch.
8. Intercanine and intermolar transverse dimen-
sions. 9.
Relative archform.
10. Infra- or supra-eruption of any teeth.
11. Rotations of specific teeth.
tioners delegate this procedure to an auxiliary is even more disturbing.
38
Forsea discovered that
impression-taking was one of the tasks associated with the highest release of cortisol, indicating in-
creased stress on the part of the operator.
39
If the
procedure in question is unnecessary and of lim-
ited therapeutic value, how can one justify jeopar-
dizing the health of a staff member?
Other considerations include the unacceptabil-
ity of clinical photographs as a substitute for models by certain certifying bodies. The ABO requires models of some type to be submitted for evaluation when seeking Board certification.
40
The Commis-
sion on Dental Competency Assessments requires the presentation of “documented cases, models, and case histories” to demonstrate the candidate’s treat-
ment-planning and technical skills.
41
Until those
agencies accept photographs in lieu of models, or do away with case presentations altogether, any cas-
es that are earmarked as “board cases” will need pre- and post-treatment models.
Another concern involves third-party payers
who mandate specific records for purposes of pre-authorization or periodic reimbursement for services rendered. Although some require models to be submitted, others will accept photographs.
A final issue pertains to research and ortho-
dontic education. Study models are preferable to photographs in obtaining detailed measurements for statistical analysis and determination of statis-
TABLE 2
AGREEMENT OF EVALUATORS ON DIAGNOSTIC CRITERIA
Case 1 Case 2 Case 3 Case 4 Case 5
Right canine classification 13/13 100% 13/13 100% 12/12 100% 13/13 100% 13/13 100%
Left canine classification 13/13 100% 13/13 100% 4/12* 33%* 13/13 100% 11/13 85%
Right molar classification 13/13 100% 11/13 85% 11/13 85% 13/13 100% 11/11 100%
Left molar classification 13/13 100% 13/13 100% 11/13 85% 11/13 85% 9/11 82%
Lower anterior palatal contact 10/13 77% 13/13 100% 13/13 100% 13/13 100% 9/12 75%
P
osterior crossbite
13/13 100% 13/13 100% 10/13 77% 12/13 92% 10/11 90%
*Canines on left side were cusp tip to cusp tip and could have been classified as either Class I or Class II.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
JERROLD, SCHULTE, ISAACS HENRY
tical significance, because these measurements
need to be more precise than the 1mm clinical
acceptability margin of error. Educational pro-
grams require study models for any number of
valid reasons. On the other hand, adequate docu-
mentation is possible with only intraoral photo-
graphs in routine lecture, educational, and
private-practice environments, especially after
some kind of calibration training.
From a clinical perspective, in the over-
whelming majority of cases and situations, there
does not seem to be any rational basis for not sub-
stituting photographs for plaster or digital models,
as long as high-quality photos can be acquired.
The following diagnostic criteria must be accurate-
ly determined, in millimeters:
1.
Canine and molar classification.
2. Anterior or posterior crossbite.
3. Depth of vertical overbite or amount of anterior
open bite. 4.
Palatal impingement by the lower anterior den-
tition. 5.
Horizontal overbite or overjet.
6. Depth of the curve of Spee.
7. Degree of crowding or spacing within each arch.
8. Intercanine and intermolar transverse dimen-
sions. 9.
Relative archform.
10. Infra- or supra-eruption of any teeth.
11. Rotations of specific teeth.
tioners delegate this procedure to an auxiliary is even more disturbing.
38
Forsea discovered that
impression-taking was one of the tasks associated with the highest release of cortisol, indicating in-
creased stress on the part of the operator.
39
If the
procedure in question is unnecessary and of lim-
ited therapeutic value, how can one justify jeopar-
dizing the health of a staff member?
Other considerations include the unacceptabil-
ity of clinical photographs as a substitute for models by certain certifying bodies. The ABO requires models of some type to be submitted for evaluation when seeking Board certification.
40
The Commis-
sion on Dental Competency Assessments requires the presentation of “documented cases, models, and case histories” to demonstrate the candidate’s treat-
ment-planning and technical skills.
41
Until those
agencies accept photographs in lieu of models, or do away with case presentations altogether, any cas-
es that are earmarked as “board cases” will need pre- and post-treatment models.
Another concern involves third-party payers
who mandate specific records for purposes of pre-authorization or periodic reimbursement for services rendered. Although some require models to be submitted, others will accept photographs.
A final issue pertains to research and ortho-
dontic education. Study models are preferable to photographs in obtaining detailed measurements for statistical analysis and determination of statis-
TABLE 2
AGREEMENT OF EVALUATORS ON DIAGNOSTIC CRITERIA
Case 1 Case 2 Case 3 Case 4 Case 5
Right canine classification 13/13 100% 13/13 100% 12/12 100% 13/13 100% 13/13 100%
Left canine classification 13/13 100% 13/13 100% 4/12* 33%* 13/13 100% 11/13 85%
Right molar classification 13/13 100% 11/13 85% 11/13 85% 13/13 100% 11/11 100%
Left molar classification 13/13 100% 13/13 100% 11/13 85% 11/13 85% 9/11 82%
Lower anterior palatal contact 10/13 77% 13/13 100% 13/13 100% 13/13 100% 9/12 75%
P
osterior crossbite
13/13 100% 13/13 100% 10/13 77% 12/13 92% 10/11 90%
*Canines on left side were cusp tip to cusp tip and could have been classified as either Class I or Class II.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
98 JCO/FEBRUARY 2019
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
Any competent dental photographer, wheth-
er orthodontist or staff member, should be able to
acquire repeatable, standardized intraoral photo-
graphs that will allow accurate measurement of
items 1-7. The other four items may be meaningful
in diagnosis and treatment planning, but are not
routinely measured in clinical practice. Assess-
ments are often subjective, such as “the maxillary
arch is narrow” or “the mandibular arch is too
wide.” A patient’s archform is almost always re-
ferred to in geometric terms such as broad, narrow,
tapered, or square. Infra- or supradental eruption,
while often referred to, is almost never measured.
Rotations are usually noted as minor or significant,
often using quarter-arch measurements such as 30°
or 90° rotated. For these reasons, we decided to
forego actual measurement of such conditions for
purposes of our preliminary investigation. Al-
though clinically valid, the study needs to be re-
peated and confirmed using a larger sample size
and photographs without flaws.
Conclusion
Addressing the original question of whether
photographs can meet the criteria for being con-
sidered a best practice within a generally accepted
standard of care, we believe the data presented
support an affirmative response. Our literature
search and preliminary clinical study indicate that
in the majority of clinical cases, photographs are
a viable substitute for plaster or digital study mod-
els. Whatever you need to know from a clinical,
risk-management, administrative, and best-
practices perspective can be determined from pho-
tographs alone, with a few caveats. From a practi-
cal perspective, models can be dispensed with—
unless they cannot. As long as third-party payers
will accept them, there should be no reason not to
interchange photographs for models in most cases.
We have no reservations in stating that intra-
oral photography, as a component of a comprehen-
sive patient examination, is a clinically acceptable
and accurate methodology for diagnosing an ortho-
dontic problem, determining the method of treat-
ment or mechanotherapy, and assessing the gener-
al outcome of treatment. Our preliminary study
has demonstrated that measurements can be ob-
tained solely through the use of calibrated intraoral
photography within a 1mm margin of error for
most parameters. Measurements that fell outside
this range had valid explanations for the discrep-
ancies, usually related to examiner error—not in
acquiring the measurement, but in defining how
the relationship should be evaluated.
REFERENCES
1.
NoLo: What is the medical standard of care in a malpractice
case? www.nolo.com/legal-encyclopedia/medical-standard-
care-malpractice-case.html, accessed Feb. 9, 2017.
2. McCourt v. Abernathy, 457 S.E.2d 603 (S.C. 1995).
3. Bretschneider, S.; Marc-Aurele, F.J. Jr.; and Wu, J.: “Best prac-
tices” research: A methodological guide for the perplexed, J.
Pub. Admin. Res. Theory 15:307-323, 2005.
4. Han, U.K.; Vig, K.W.L.; Weintraub, J.A.; Vig, P.S.; and
Kowalski, C.J.: Consistency of orthodontic treatment decisions relative to diagnostic records, Am. J. Orthod. 100:212-219, 1991.
5.
American Association of Orthodontists: Patient records and
recordkeeping, www.aaoinfo.org/legal-advocacy/legal-issues/ patient-records-and-record-keeping, accessed Dec. 28, 2017.
6.
American Association of Orthodontists: AAO leads effort to
standardize medically necessary orthodontic care criteria, www.aaoinfo.org/news/2016/05/aao-leads-effort-standardize-
medically-necessary-orthodontic-care-criteria, May 27, 2016, accessed Feb. 15, 2017.
7.
Callahan, C.; Sadowsky, P.L.; and Ferreira, A.: Diagnostic value
of plaster models in contemporary orthodontics, Semin. Orthod. 11:94-97, 2005.
8.
Yetter, N. and Rinchuse, D.J.: The value of orthodontic study
models for diagnosis and treatment planning: A survey, Orthod. Pract. U.S. 6:56-58, 2015.
9.
Aragon, M.L.; Pontes, L.F.; Bichara, L.M.; Flores-Mir, C.; and
Normando, D.: Validity and reliability of intraoral scanners compared to conventional gypsum models measurements: A systematic review, Eur. J. Orthod. 38:429-434, 2016.
10.
Santoro, M.; Galkin, S.; Teredesai, M.; Nicolay, O.F.; and
Cangialosi, T.: Comparison of measurements made on digital and plaster models, Am. J. Orthod. 124:101-105, 2003.
11.
Bell, G.L.: Missing and unidentified persons, in Forensic Dental
Evidence: An Investigator’s Handbook, 2nd ed., ed. M.C.
Bowers, Academic Press, Cambridge, MA, 2010.
12. Wiranto, M.G.; Engelbrecht, W.P.; Tutein Nolthenius, H.E.; van
der Meer, W.J.; and Ren, Y.: Validity, reliability, and reproduc-
ibility of linear measurements on digital models obtained from intraoral and cone-beam computed tomography scans of algi- nate impressions, Am. J. Orthod. 143:140-147, 2013.
13.
Mok, C.W.; Zhou, L.; McGrath, C.; Hagg, U.; and Bendeus, M.:
Digital images as an alternative to orthodontic casts in assessing malocclusion and orthodontic treatment need, Acta Odontol. Scand. 65:362-368, 2007.
14.
Stevens, D.R.; Flores-Mir, C.; Nebbe, B.; Raboud, D.W.; Heo,
G.; and Major, P.W.: Validity, reliability, and reproducibility of plaster vs digital study models: Comparison of peer assessment rating and Bolton analysis and their constituent measurements, Am. J. Orthod. 129:794-803, 2006.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
INTRAORAL PHOTOGRAPHY VS. PLASTER AND DIGITAL MODELS
Any competent dental photographer, wheth-
er orthodontist or staff member, should be able to
acquire repeatable, standardized intraoral photo-
graphs that will allow accurate measurement of
items 1-7. The other four items may be meaningful
in diagnosis and treatment planning, but are not
routinely measured in clinical practice. Assess-
ments are often subjective, such as “the maxillary
arch is narrow” or “the mandibular arch is too
wide.” A patient’s archform is almost always re-
ferred to in geometric terms such as broad, narrow,
tapered, or square. Infra- or supradental eruption,
while often referred to, is almost never measured.
Rotations are usually noted as minor or significant,
often using quarter-arch measurements such as 30°
or 90° rotated. For these reasons, we decided to
forego actual measurement of such conditions for
purposes of our preliminary investigation. Al-
though clinically valid, the study needs to be re-
peated and confirmed using a larger sample size
and photographs without flaws.
Conclusion
Addressing the original question of whether
photographs can meet the criteria for being con-
sidered a best practice within a generally accepted
standard of care, we believe the data presented
support an affirmative response. Our literature
search and preliminary clinical study indicate that
in the majority of clinical cases, photographs are
a viable substitute for plaster or digital study mod-
els. Whatever you need to know from a clinical,
risk-management, administrative, and best-
practices perspective can be determined from pho-
tographs alone, with a few caveats. From a practi-
cal perspective, models can be dispensed with—
unless they cannot. As long as third-party payers
will accept them, there should be no reason not to
interchange photographs for models in most cases.
We have no reservations in stating that intra-
oral photography, as a component of a comprehen-
sive patient examination, is a clinically acceptable
and accurate methodology for diagnosing an ortho-
dontic problem, determining the method of treat-
ment or mechanotherapy, and assessing the gener-
al outcome of treatment. Our preliminary study
has demonstrated that measurements can be ob-
tained solely through the use of calibrated intraoral
photography within a 1mm margin of error for
most parameters. Measurements that fell outside
this range had valid explanations for the discrep-
ancies, usually related to examiner error—not in
acquiring the measurement, but in defining how
the relationship should be evaluated.
REFERENCES
1.
NoLo: What is the medical standard of care in a malpractice
case? www.nolo.com/legal-encyclopedia/medical-standard-
care-malpractice-case.html, accessed Feb. 9, 2017.
2. McCourt v. Abernathy, 457 S.E.2d 603 (S.C. 1995).
3. Bretschneider, S.; Marc-Aurele, F.J. Jr.; and Wu, J.: “Best prac-
tices” research: A methodological guide for the perplexed, J.
Pub. Admin. Res. Theory 15:307-323, 2005.
4. Han, U.K.; Vig, K.W.L.; Weintraub, J.A.; Vig, P.S.; and
Kowalski, C.J.: Consistency of orthodontic treatment decisions relative to diagnostic records, Am. J. Orthod. 100:212-219, 1991.
5.
American Association of Orthodontists: Patient records and
recordkeeping, www.aaoinfo.org/legal-advocacy/legal-issues/ patient-records-and-record-keeping, accessed Dec. 28, 2017.
6.
American Association of Orthodontists: AAO leads effort to
standardize medically necessary orthodontic care criteria, www.aaoinfo.org/news/2016/05/aao-leads-effort-standardize-
medically-necessary-orthodontic-care-criteria, May 27, 2016, accessed Feb. 15, 2017.
7.
Callahan, C.; Sadowsky, P.L.; and Ferreira, A.: Diagnostic value
of plaster models in contemporary orthodontics, Semin. Orthod. 11:94-97, 2005.
8.
Yetter, N. and Rinchuse, D.J.: The value of orthodontic study
models for diagnosis and treatment planning: A survey, Orthod. Pract. U.S. 6:56-58, 2015.
9.
Aragon, M.L.; Pontes, L.F.; Bichara, L.M.; Flores-Mir, C.; and
Normando, D.: Validity and reliability of intraoral scanners compared to conventional gypsum models measurements: A systematic review, Eur. J. Orthod. 38:429-434, 2016.
10.
Santoro, M.; Galkin, S.; Teredesai, M.; Nicolay, O.F.; and
Cangialosi, T.: Comparison of measurements made on digital and plaster models, Am. J. Orthod. 124:101-105, 2003.
11.
Bell, G.L.: Missing and unidentified persons, in Forensic Dental
Evidence: An Investigator’s Handbook, 2nd ed., ed. M.C.
Bowers, Academic Press, Cambridge, MA, 2010.
12. Wiranto, M.G.; Engelbrecht, W.P.; Tutein Nolthenius, H.E.; van
der Meer, W.J.; and Ren, Y.: Validity, reliability, and reproduc-
ibility of linear measurements on digital models obtained from intraoral and cone-beam computed tomography scans of algi- nate impressions, Am. J. Orthod. 143:140-147, 2013.
13.
Mok, C.W.; Zhou, L.; McGrath, C.; Hagg, U.; and Bendeus, M.:
Digital images as an alternative to orthodontic casts in assessing malocclusion and orthodontic treatment need, Acta Odontol. Scand. 65:362-368, 2007.
14.
Stevens, D.R.; Flores-Mir, C.; Nebbe, B.; Raboud, D.W.; Heo,
G.; and Major, P.W.: Validity, reliability, and reproducibility of plaster vs digital study models: Comparison of peer assessment rating and Bolton analysis and their constituent measurements, Am. J. Orthod. 129:794-803, 2006.?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
99VOLUME LIII NUMBER 2
JERROLD, SCHULTE, ISAACS HENRY
graphs: The gold standard, an update, Prog. Orthod. 13:296-303,
2012.
29. Jerrold, L.: Clinical practice guidelines regarding orthodontic
record taking, developed for Smile Brands, Inc., 2017.
30. Sandler, J.; Dwyer, J.; Kokich, V.; McKeown, F.; Murray, A.;
McLaughlin, R.; O’Brien, C.; and O’Malley, P.: Quality of clin-
ical photographs taken by orthodontists, professional photog-
raphers, and orthodontic auxiliaries, Am. J. Orthod. 135:657- 662, 2009.
31.
Almasoud, N. and Bearn, D.: Little’s Irregularity Index:
Photographic assessment vs study model assessment, Am. J. Orthod. 138:787-794, 2010.
32.
Mandall, N.A.: Are photographic records reliable for ortho-
dontic screening? J. Orthod. 29:125-127, 2002.
33. Ferrucci, M.; Doiron, T.; Thompson, R.; Jones, J.; Freeman, A.;
and Neiman, J.A.: Dimensional review of scales for forensic photography, J. Forensic Sci. 61:509-519, 2016.
34.
Tomita, Y. and Honda, S.: Experimental evaluation of instru-
ment scale readings obtained by eye interpolation of fractional interval values, Measurement 13:147-151, 1994.
35.
Madhan, B. and Gayathri, H.: Identification and prevention of
digital forgery in orthodontic records, Am. J. Orthod. 138:850- 857, 2 010.
36.
Burris, B.G.: Communications in moving from hi to buy, Semin.
Orthod. 22:95-99, 2016.
37. Moskowitz, E.M.: Communication by way of the consultation,
Semin. Orthod. 22:100-102, 2016.
38. Keim, R.G.; Gottlieb, E.L.; Vogels, D.S. III; and Vogels, P.B.:
2015 JCO Practice Study, Part 1: Trends, J. Clin. Orthod. 69:625-639, 2015.
39.
Forsea, J. and Jerrold, L.: A measure of stress, Orthod. Prod.
September 2003.
40. American Board of Orthodontics: Clinical examination, www.
americanboardortho.com/orthodontic-professionals/ about-board-certification/clinical-examination/case-
record-preparation/digital-models, accessed March 3, 2017.
41.
Commission on Dental Competency Assessments: Specialty
Exams, www.cdcaexams.org/specialty-exam, accessed March 19, 2 017.
15.
Jung, Y.R.; Park, J.M.; Chun, Y.S.; Lee, K.N.; and Kim, M.:
Accuracy of four different intraoral scanners: Effects of the presence of orthodontic brackets and wire, Int. J. Comput. Dent. 19:203-215, 2016.
16.
Hove, L.H.; Mulic, A.; Tveit, A.B.; Stenhagen, K.R.; Skaare,
A.B., and Espelid, I.: Registration of dental erosive wear on study models and intra-oral photographs, Eur. Arch. Paediat. Dent. 14:29-34, 2013.
17.
Ellis, P.E. and Benson, P.E.: Does articulating study casts make
a difference to treatment planning? J. Orthod. 30:274, 2003.
18. Keating, A.P.; Knox, J.; Bibb, R.; and Zhurov, A.I.: A compari-
son of plaster, digital and reconstructed study model accuracy, J. Orthod. 35:191-201, 2008.
19.
Goonewardene, R.W.; Goonewardene, M.S.; Razza, J.M.; and
Murray, K.: Accuracy and validity of space analysis and irreg-
ularity index measurements using digital models, Austral. Orthod. J. 24:83-90, 2008.
20.
Horton, H.M.; Miller, J.R.; Gaillard, P.R.; and Larson, B.E.:
Technique comparison for efficient orthodontic tooth measure-
ments using digital models, Angle Orthod. 80:254-261, 2010.
21. Fleming, P.S.; Marinho, V.; and Johal, A.: Orthodontic measure-
ments on digital study models compared to plaster models: A systematic review, Orthod. Craniofac. Res. 14:1-16, 2011.
22.
Leifert, M.F.; Leifert, M.M.; Efstratiadis, S.S.; and Cangialosi,
T.J.: Comparison of space analysis evaluations with digital mod-
els and plaster dental casts, Am. J. Orthod. 136:16.e1-4, 2009.
23. Magness, W.B.: Plan your work and work your plan: Designing
personalized treatment plans with VTOs, Orthotown, December:38-46, 2016.
24.
Akyalcin, S.; Cozad, B.E.; English, J.D.; Colville, C.D.; and
Laman, S.: Diagnostic accuracy of impression-free digital mod-
els, Am. J. Orthod. 144:916-922, 2013.
25. Ahmad, I.: Digital dental photography, Part 1: An overview, Br.
Dent. J. 206:403-407, 2009.
26. Reddy, S.P.; Kashyap, B.; Sudhakar, S.; Guru, J.R.; and Nalini,
P.: Evaluation of dental photography among dental profession-
als, J. Ed. Ethics Dent. 4:4-7, 2014.
27. Ahmad, I.: Digital dental photography, Part 2: Purposes and
uses, Br. Dent. J. 206:459-464, 2009.
28. Sandler, J.; Gutierrez, R.J.; and Murray, C.: Clinical photo-?2019 JCO, Inc. May not be distributed without permission. www.jco-online.com
JERROLD, SCHULTE, ISAACS HENRY
graphs: The gold standard, an update, Prog. Orthod. 13:296-303,
2012.
29. Jerrold, L.: Clinical practice guidelines regarding orthodontic
record taking, developed for Smile Brands, Inc., 2017.
30. Sandler, J.; Dwyer, J.; Kokich, V.; McKeown, F.; Murray, A.;
McLaughlin, R.; O’Brien, C.; and O’Malley, P.: Quality of clin-
ical photographs taken by orthodontists, professional photog-
raphers, and orthodontic auxiliaries, Am. J. Orthod. 135:657- 662, 2009.
31.
Almasoud, N. and Bearn, D.: Little’s Irregularity Index:
Photographic assessment vs study model assessment, Am. J. Orthod. 138:787-794, 2010.
32.
Mandall, N.A.: Are photographic records reliable for ortho-
dontic screening? J. Orthod. 29:125-127, 2002.
33. Ferrucci, M.; Doiron, T.; Thompson, R.; Jones, J.; Freeman, A.;
and Neiman, J.A.: Dimensional review of scales for forensic photography, J. Forensic Sci. 61:509-519, 2016.
34.
Tomita, Y. and Honda, S.: Experimental evaluation of instru-
ment scale readings obtained by eye interpolation of fractional interval values, Measurement 13:147-151, 1994.
35.
Madhan, B. and Gayathri, H.: Identification and prevention of
digital forgery in orthodontic records, Am. J. Orthod. 138:850- 857, 2 010.
36.
Burris, B.G.: Communications in moving from hi to buy, Semin.
Orthod. 22:95-99, 2016.
37. Moskowitz, E.M.: Communication by way of the consultation,
Semin. Orthod. 22:100-102, 2016.
38. Keim, R.G.; Gottlieb, E.L.; Vogels, D.S. III; and Vogels, P.B.:
2015 JCO Practice Study, Part 1: Trends, J. Clin. Orthod. 69:625-639, 2015.
39.
Forsea, J. and Jerrold, L.: A measure of stress, Orthod. Prod.
September 2003.
40. American Board of Orthodontics: Clinical examination, www.
americanboardortho.com/orthodontic-professionals/ about-board-certification/clinical-examination/case-
record-preparation/digital-models, accessed March 3, 2017.
41.
Commission on Dental Competency Assessments: Specialty
Exams, www.cdcaexams.org/specialty-exam, accessed March 19, 2 017.
15.
Jung, Y.R.; Park, J.M.; Chun, Y.S.; Lee, K.N.; and Kim, M.:
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