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Abstract

With exceptional progress in the field of electronics, newer diagnostic modalities have become popular in medicine. Out of the several gadgets invented, smartphones are the handiest and celebrated innovations of the world. The usage of smartphones has had a colossal influence on individuals and society in all aspects of daily life such as the economy, education, and communication just to mention a few. It also has an extended spread to many sectors, including health care and dentistry with multifarious benefits. Today, several orthodontic applications are available as software on computers and smartphones. The applications can process diagnosis, provide a good doctor–patient interface, and also cater to patient needs. Concerning orthodontics, diagnosis is of high priority, with radiographic analysis being the most crucial step. At the moment, several applications are available on smartphones to perform cephalometric analysis using radiographs. Just with a few clicks, cephalometric analysis can be performed, and the results are displayed in a flash. Only a minor number of orthodontists are enlightened about the operation of smartphones for cephalometric analysis. To elicit awareness, a narrative review has been performed on the software for cephalometric analysis available on smartphones. This article reviews the reliance of smartphones for the assessment of cephalometric analysis.

Keywords

Smartphone cephalometric analysis orthodontics android based applications apple based applications free of cost

Novelty

Many articles have been published, regarding the usage of smartphones for cephalometric analysis, but no article until now has reviewed several applications and drawn their benefits. This study provides clinicians and students a variety of applications used for cephalometric analysis on smartphones. Considering that computerized cephalometric software amounts from ₹200,000 to ₹400,000, the smartphone cephalometric applications range from free of cost to a maximum of ₹7359.66, inclusive of in-app purchases. With this benefit of buying time, cost-friendly and accurate diagnostic potential of smartphone cephalometric analysis, the applications will be a viable option.

Introduction

The benefits and excellence of radiography as a diagnostic gift in orthodontics were first demonstrated by W.A. Price in 1900, 5 years after the discovery of X-rays.¹ The procedure of radiographic cephalometry was later derived from firm and deep-rooted anthropological craniometric studies and the adoption of the Broadbent–Bolton cephalometer invented in 1931.¹ The most standardized procedure of making a lateral cephalogram is by using the head positioning cephalometer (cephalostat).¹ The patient is positioned within the cephalostat, using adjustable bilateral ear rods—one in each auditory meatus—and with the Frankfurt plane parallel to the floor.¹ As a result, a series of lateral skull radiographs are obtained in a standardized manner, thus creating a reproducible beam/film/patient projection geometry.¹ This, in turn, allows a comparison of structures and also allows making precise measurements on the radiographs either directly or by superimposing the tracings.¹

Speaking of lateral cephalography, lateral cephalogram is one of the five essential diagnostic aids used in orthodontics. It is an indispensable tool.² It is used to diagnose, provide treatment plans, evaluate treatment results, study growth and development, monitor analysis, and is also used for research purposes.^1-11,13-15 Traditionally, lateral cephalograms are traced manually on cellulose acetate overlays with the assistance of a millimeter ruler, a protractor, a 0.3-mm lead pencil, and a good quality viewBox.^7,15 This procedure has remained the gold standard for untold years.^2,6,9 Despite its pandemic use, the procedure is cumbersome and time-impeding, and the radiographs tend to deteriorate over a while and require room for storage. Errors with manual tracing occur due to superimposition of the structures present, making it difficult to identify landmarks, improper tracing, and calculations procedures; besides, errors also occur due to human fatigue.^2-11,13-15

Advancements in the field of computerized radiography over the past decades have led digital radiographs to gain popularity.¹² With this invention, digital tracing has gradually replaced manual tracing methods.³ The computerized cephalometric software has several advantages—it is user friendly, provides the benefit of time, requires only limited storage space, allows manipulation of image size and contrast adjustment of the radiograph, and radiation exposure is comparatively low and superimposition errors are avoided.^2-11,13-15 The main disadvantage of the computerized cephalometric software is that it is expensive.³ Because of this, many orthodontists did not consider investing in the computerized cephalometric software.

The existing generation of smartphones is increasingly viewed as handheld computers rather than as mobile phones.¹⁶ Gone is the era when smartphones were used only to make phone calls. Today, smartphones provide us with copious extra features such as calculator, reminders, fitness, alarm, e-mail, weather, movie-making, just to name a few.¹⁶ The development of smartphones has provided new opportunities to integrate mobile technology into routine dental practice.¹⁶ Intrigued by the possibility of using smartphones for cephalometric analysis, rigorous research was performed.¹⁰ Subsequently, a countable number of software solutions for cephalometric analysis was developed as applications on smartphones. A smartphone application is a small-scale specialized software program that can be downloaded onto a gadget.¹⁷ A few applications available on the mobile phone are OneCeph, CephNinja Pro, Cephalometric Analysis, Orthonet, Cephalometria De Ricketts, Cephalometria De Steiner, Cephalometria De Ricketts 2, Easy ceph and Ceph app (Table 1). These applications allow orthodontists to perform analysis in a short duration and also transfer data in a jiffy to other devices. Out of the above-mentioned applications, most of them are free of cost. Not only do mobile phones benefit orthodontists with cephalometric analysis, but there is also a wealth of information provided, much of which can be openly accessed by doctors and patients.¹⁶

Table 1.

Details of the Applications Available on Smartphones.

S No.	Mobile Applications	Storage Space Required*	Developer Company Name	Cost
1	OneCeph (v Beta 9)	3.8 MB	NXS	Free
2	CephNinja S or Pro (v 3.66)	44.6.7 MB	Cyncronus LLC	Free for a Wits Appraisal, Jarabak’s ratio and Burstone analysis. The payment has to be made for custom composite, down’s, composite, Eastman, McNamara, soft tissue composite, Steiner’s and Tweed’s after a 2-week free trial at a cost of ₹849per month and ₹7359.66 per month annually.
3	Cephalometric analysis	6.8 MB	Bogdan SCANTEIE	₹2333.34per month
4	Orthonet	3.8 MB	Bogdan SCANTEIE	Free
5	Cephalometria de Ricketts	10 MB	CR Education	Free
6	Cephalometria de Steiner	7.5 MB	CR Education	Free
7	Cephalometria de Ricketts 2	9.1 MB	CR Education	Free
8	EasyCeph (v 3.2)	7.05 MB	Dr KTSS Rajajee	Freed
9	CEPH App	25 MB	Technocenter Orthokinetor	FREE
10	WebCeph	13 MB	Assemble circle	FREE

Note: Storage space varies when the application receives an update.

Rigorous research was performed by using keywords, and a total of 55 articles were obtained. Android and apple-based smartphones were also employed for this review. The keyword “cephalometric analysis” was typed into the “Google Play Store” or “App Store,” and a total of eight applications were found suitable for the review. Each application was downloaded and tested based on performance, cost, and ease of usage.

According to Pavan Kumar Mamillapalli et al., traditional cephalometric analysis is time protracting and technically demanding. So, he and his team developed an application called “OneCeph,” which provides a convenient interface with the most commonly used analyses. It is available for free and can be downloaded from Google Play Store. He said that the above-mentioned application simplifies a very complex and time-impeding task like cephalometric analysis. He also added that it provides structured reference and improves e-learning skills.¹⁰ According to Shettigar et al. the application “One ceph” proved to be accurate in diagnosis when tested against Dolphin software.¹⁸

According to Mayuresh Jagannath Baheti et al., the usage of smartphones has made life easy going. Both the patients and doctors are profited by this invention.¹⁶

According to Gulsilay Sayar et al., smartphone cephalometric tracing is a fast process. They had employed “Ceph Ninja 3.10” for their study. A comparison of cephalometric analysis through Steiner’s method was made by manual tracing and by smartphone application analysis. The SNA, SNB, ANB, Go-Gn/SN, and U1-NA (in ˚ and mm) values were lower by manual tracing. Although statistically significant differences were seen, the values were clinically acceptable. They concluded that the zoom-in function helps magnify images and mark the landmarks appropriately. They also added that smartphone cephalometric analysis is a “game-changer.”¹⁷

According to Aksakalli Hilal et al., for any application to be used, it should be safe, reliable, precise, and highly reproducible. In their study, they employed two smartphone applications “Smartceph Pro” and “CephNinja.” Cephalometric analysis was performed on the two above-mentioned applications, and the results were compared to Dolphin Imaging software—a computerized cephalometric analysis program. The results showed that Dolphin Imaging software and CephNinja had 7 measurements in common, while Dolphin and SmartCeph had 6 measurements in common. In both the smartphone applications, angular measurements had higher reliability than linear measurements. Errors in values were caused due to a lack of calibration or due to image distortion. Also, the three programs employed in the study were semi-automatic programs, which could result in a few errors.¹⁹

It should be taken into account that at the time of publication, certain applications may have been added, while some may have been withdrawn.¹⁶ This study was mainly carried out to provide orthodontists with a handy application to perform cephalometric analysis and also throw light on the various modalities available for cephalometric analysis. The data of studies that were carried out to determine the accuracy and reliability of smartphone applications are tabulated in Table 2.

Table 2.

Studies Assessing the Usability of Smartphone Applications for Cephalometric Analysis.

S No.	Article	Sample Size and Methodology	Parameters Assessed	Intra-observer Variability and Statistics	Remarks
1	Sayar¹⁷	55 lateral cephalographs were chosen to perform Stenier’s analysis, using CephNinja 3.10 app and manual tracing method, and the results were compared. The duration difference between the two methods were also assessed.	SNA, SNB, ANB, U1-NA⁰, L1-NB⁰, Go-GN/SN, occlusal plane to SN, interincisal angle, U1-NA (mm), L1-NB (mm), upper-lip protrusion, and lower-lip protrusion.	The results were evaluated with the 95% confidence intervals (CIs); significance level was set at P < .05. To avoid inter-examiner error, only one examiner performed the analysis and reassessed the same after 20 days. The performance duration of the manual method was significantly higher (P < .001) than the app method. The SNA and SNB values for the manual method were significantly lower (P < .001) than the app method.	• Composite analysis can be performed • Smartphone-based cephalometric analysis is a time-saving procedure and is a potential game changer. • Zoom-in feature on mobile phones allows precise location of and assessment of landmarks and parameters. • There were statistically significant differences but were not clinically significant.
				The ANB, Go-GN/SN, U1-NA⁰ and U1-NA (mm), and upper-lip protrusion values using the manual method were statistically lower than the app method.The L1-NB⁰ values using manual method were statistically greater than the app method.No differences between the manual and app methods for L1-NB (mm), occlusal plane to SN, interincisal angle, and lower-lip protrusion values.The ICC values for all parameters ranged between 0.9100 and 0.9726, showing good corelation.
2	Shettigar et al¹⁸	50 patients were chosen, and cephalometric analysis was carried out, using OneCeph mobile application and computerized Dolphin Imaging software. The results were compared.	SNA, SNB, ANB, Max Mand Plane, U1/Max Plane, L1/Mand Plane, U1-L1, Lower-Lip/E Line, Anterior Cranial Base, Wits (mm), FMA, saddle angle, articular angle, gonial angle, and sum of angles.	Only one examiner performed the analysis to avoid inter-examiner error.P value was set at P < .05 and Paired t-test was performed.Basal plane angle, SNB, L1-MP, FMA showed significant differences between the two methods.High positive correlation between the parameters obtained from the Dolphin and OneCeph was observed using Karl Pearson’s method.	• A high compatibility was noticed between Dolphin Imaging software and OneCeph application;• User-friendly application; and• High degree of accuracy and reliability with mobile phone application is observed.
3	Aksakalli et al¹⁹	20 patient’s radiographs were randomly selected and traced using CephNinja app, SmartCeph Pro app, and Dolphin Imaging software.The values obtained from CephNinja app and SmartCeph Pro app were compared to Dolphin Imaging software.	SNA, SNB, ANB, Max Mand Plane, Anterior Cranial Base, Wits (mm), FMA, saddle angle, articular angle, gonial angle, sum of angles, U1/Max Plane, L1/Mand Plane, U1-L1, lower-lip/E line, upper-lip/E line.	Only one examiner carried out the analysis and re-examined values after 7 days.P value was set at P = .05.Blandt–Altman analysis was utilized.For CephNinja–Dolphin comparison, no statistically significant differences were found for anterior cranial base, FMA, articular angle, gonial angle, L1/mandibular plane, and sum of angles. For SmartCeph Pro-Dolphin comparison, no statistically significant differences were seen for	• Angular measurements are more reliable than linear measurements.• The mobile applications are not as reliable and accurate as computerized applications.• Further development in accuracy is required.
				SNA, Max Mand plane, U1/Max Plane, L1/Mand Plane, upper lip/E and Ant Cranial base angles.CephNinja and SmartCeph Pro gave lower values than Dolphin software for SNA and SNB.The Pearson correlation coefficients was above 0.900 for all parameters
4	Livas et al²⁰	50 lateral cephalograms were traced using CephNinja and OneCeph and were compared to manual tracing.	SNA, SNB, ANB, SN-GoGn, upper incisor to NA in (degrees and mm), lower incisor to NB in (degrees and mm), and interincisal angle.	To avoid inter-observer variability, a single examiner performed the analysis and reassessed the same after 14 days.Analysis of variance, Mauchly’s test, paired t-test, Blandt–Altman’s plot intra-class correlation coefficient, and the 95% confidence intervals (CIs) were calculated.SN-GoGn and L1-NB (mm) as measured using CephNinja and OneCeph were significantly different from the ViewBox values. U1-NA (mm) in OneCeph was significantly different compared to manual method.Intra-class correlation coefficients (ICCs) ranged from 0.903–0.983 for OneCeph versus ViewBox and 0.786-0.978 CephNinja versus ViewBox.The ICC values for intra-tool reliability ranged from 0.647-0.993.	• The best alternative to a viewBox was CephNinja• More accurate and reliable values were obtained from OneCeph.• Image magnification and adjustment of brightness are an added advantage.• Smartphones are a great supplemental tool in comparison to a viewBox.
5	Khader et al²¹	40 lateral cephalograms were traced manually and compared to OneCeph application tracing.	Incisal mandibular plane angle (IMPA), facial mandibular angle (FMA), and facial mandibular incisal plane angle (FMIA).	To avoid inter-observer variability, a single examiner traced the radiographsThe level of significance was kept at P < .05.Student t-test and Shapiro–Wilk test were used.IMPA, FMIA, and FMA values of OneCeph and manual analysis were found to be statistically insignificant.	• OneCeph application is as reliable as manual tracing.
6	Kohli²²	30 lateral cephalograms were traced manually and using CephNinja version 3.31.	SNA, SNB, ANB, SN/Go-Gn, U1-NA⁰, L1-NB⁰, U1/L1, U1-NA in mm, and L1-NB in mm.	To avoid inter-observer variability, a single examiner performed the analysis and retraced the same after 21 days.The level of statistical significance was set at P < .05. Student t-test was used.Intra-class correlation coefficient was set as >0.75, indicating good agreement.SNA and SNB showed highest correlation values. All parameters have ICC > 0.75, indicating high agreement between both the tracing techniques.Paired t-test revealed that for all parameters, there were statistically similar differences between smartphone-assisted tracing and manual tracing.	• Smartphones are the most cost effective and portable tools for cephalometric analysis;• Is an evolving tool for clinical decision-making; and• Easy to use.
7	Kumar et al²³	100 pre-treatment lateral cephalograms were traced using CephNinja and Nemoceph computerized application	Facial angle, angle of convexity, A–B plane angle, mandibular plane angle, Y-axis, Cant of occlusal plane, interincisal angle, incisor occlusal plane angle, incisor mandibular plane angle, and U1-A-Pog (linear).	One-way ANOVA followed by post hoc test was performed.P value was set at P ≤ .5 as significant.Y-axis, incisor occlusal plane angle, and the upper incisor to A-Pog showed statistically significant differences between the two software.	• CephNinja is a pocket-friendly alternative to computerized cephalometric analysis• Cost-effective and easy to use application.

Conclusion

The results show good reliability of the smartphone cephalometric applications.

The analysis performed can be transferred via e-mail, WhatsApp, or even through Bluetooth in a matter of a few minutes.

Calibration of images before performing analysis is essential to avoid errors of magnification.

Smartphone cephalometric analysis using “OneCeph” is a time-saving procedure and can also perform composite analysis by adding the required parameters to favorites. It definitely has an upper hand for the time being, as it is free of cost and can perform unlimited cases, but it has the disadvantage of availability only on Android-based smartphones. It is the most user-friendly and accurate application, as it has a very methodological approach and also has numerous options for sharing the data.

Considering that computerized cephalometric software amounts from ₹2,00,000 to ₹4,00,000, the smartphone cephalometric applications range from free of cost to a maximum of a few thousands of rupees inclusive of in-app purchases.

CephNinja Pro is a revolutionary application, which can be downloaded only on Apple-based devices and allows not only cephalometric analysis to be performed but also provides photographic analysis and patient management features. It has a drawback of being a paid application, but the application will be launching a new artificial intelligence version, where landmarks will be marked automatically, making cephalometric analysis a cakewalk experience.

SmartCeph Pro is not reliable for Wits Appraisal.

OneCeph and CephNinja are undoubtedly the most commonly used smartphone applications

Mesh Terms

Smartphone, cephalometric analysis, orthodontics, android-based applications, Apple-based applications, free of cost, computerized cephalometric software, smartphone cephalometric software, and recent advances in cephalometric analysis.

Footnotes

Declaration of Conflicting Interest

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Goutham N

Neeharika S

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Handy Gadget for Cephalometric Analysis: A Systematic Review

Abstract

Keywords

Novelty

Introduction

Details of the Applications Available on Smartphones.

Studies Assessing the Usability of Smartphone Applications for Cephalometric Analysis.

Conclusion

Mesh Terms

Footnotes

Declaration of Conflicting Interest

Funding

ORCID iDs

References