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Computerized Medical Imaging and Graphics 28 (2004) 401409

Image processing for craniofacial landmark identification and

measurement: a review of photogrammetry and cephalometry
Tania S. Douglas*
MRC/UCT Medical Imaging Research Unit, Department of Human Biology, Faculty of Health Sciences,
University of Cape Town, Observatory 7925, South Africa
Received 12 January 2004; accepted 18 June 2004

Facial surface anthropometry and cephalometry have been used for many years for the diagnosis of malformations, surgical planning and
evaluation, and growth studies. These disciplines rely on the identification of craniofacial landmarks. Methods for 3D reconstruction of
landmarks have been introduced, as have image processing algorithms for the automation of landmark extraction. This paper reviews
facial surface anthropometry and cephalometry with reference to the image processing algorithms that have been applied and their
q 2004 Elsevier Ltd. All rights reserved.

Keywords: Anthropometry; Cephalogram; Craniofacial; Facial; Feature extraction; Image processing; Landmark; Photogrammetry; Shape analysis; Stereo

1. Introduction planning, evaluation of treatment outcome and growth

prediction and monitoring.
Anthropometry provides objective means to assess facial Anthropometric and cephalometric studies are based on
shape and detect shape changes over time, in order to biological homology, i.e. spatial correspondence between
diagnose genetic and acquired malformations, to plan and definable points on structures in individuals, and geometric
evaluate surgery, to study normal and abnormal growth and variation in the relative location or pattern of these points or
to differentiate between the results of treatment and normal landmarks [3]. Craniofacial form is defined by size and
growth. While the term anthropometry covers measurement shape, and both are analyzed. Quantitatively determining
of any aspect of the human form, the term surface the extent of deviation of an individuals facial pattern from
anthropometry is used in this paper to refer to the the normal state requires the collection of data on normal
measurement of surface features, while cephalometry individuals in order to establish numerical descriptions of
refers to the analysis of craniofacial features from X-ray normal measurement ranges. Syndrome diagnosis requires
images of the head, or cephalograms. the definition of characteristic abnormal patterns associated
Surface anthropometry for the assessment of facial with a given syndrome. Growth studies require facial
features in dysmorphic patients was first used for facial pattern changes to be monitored over time. Surgical
clefts and now provides a quantitative basis for pattern planning requires visualization and quantification of
recognition and syndrome diagnosis [1], through the dysmorphic features and the ability to model the changes
establishment of firm diagnostic criteria as well as the that surgery is expected to bring about.
demonstration of the range of variability of expression of Image processing algorithms applied to facial images
any given syndrome [2]. Cephalometry is widely used to have the potential to enhance anthropometric applications
study the bony structure of the face for diagnosis, treatment through reductions in the time spent on examinations and
improvements in the reliability of measurements. Automatic
* Tel.: C27-21-406-6541; fax: C27-21-448-7226. extraction of desired facial features or landmarks would
E-mail address: enable automatic measurement of clinically relevant
0895-6111/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
402 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409

distances and angles, as well as shape analysis and consistent errors in some facial distances obtained from 2D
comparison. This paper reviews landmark localization photogrammetry; only 20 of 60 measurements from
from facial photographs and cephalograms, concentrating photographs showed acceptable values when compared
on those methods that have used image processing with direct measurements. The 2D nature of prints as well as
algorithms to provide a degree of automation; many landmarks that were not visible or obscured by hair
interesting applications of surface anthropometry and prevented the measurement of 40 features from
cephalometry which have not been enhanced by image single photographs out of 100 that are available using
processing, are therefore not covered here. direct methods [5]. Based on comparison with direct
measurements using calipers, Astley and Clarren [12]
found that the addition 7% to the palpebral fissure lengths
2. Photogrammetry measured from frontal photographs was necessary in order
to compensate for the loss of depth information. Ratios of
Facial measurement from photographs as an alternative facial distances, angles and triangles connecting landmark
to direct measurement using instruments such as rulers or points obtained from photographs have been used as proxy
calipers has been introduced both in 2D and 3D measures for absolute distances, where photographs lacked
applications. Photogrammetry is the process of obtaining internal measures of scale [4,13,14].
measurements by means of photographs, while stereo Methods of capturing 3D surface facial structure without
photogrammetry refers to the special case, where two or the use of photographs include laser surface scanning [15],
more cameras are used to obtain 3D information of a scene. Moire topography and contour photography [9], the use of
In line with these definitions, the term photogrammetry, electromagnetic digitizers [16] and the detection of
when used by anthropometrists, has generally referred to reflective markers by infrared cameras [8].
measurement from photographs [1,4,5]. However, in the Laser scanning utilizes low-power laser beams, projected
fields of research concerned with imaging of architectural onto the face while the subject is rotated with respect to the
and geological structures (e.g. remote sensing and beams, and viewed from an oblique angle by a video
geomatics), photogrammetry is often used to refer to 3D camera. It requires a set facial expression during a scanning
reconstruction from 2D images; when researchers from period of several seconds and does not capture surface
these fields have transferred their techniques to medical texture. Both Moire topography and contour photography
applications, their usage of the term has persisted [6]. In this project grids onto the subject resulting in contour lines on
paper, the term stereo photogrammetry will be used to the pictures from which the 3D coordinates of points are
indicate the derivation of 3D information of objects from determined. These methods are well suited to the capture of
their 2D images, while single or 2D photogrammetry will gently curving surfaces such as the human back but result in
refer to measurement from single photographs. sparse facial data on features with high levels of depth
Several advantages of indirect methods such as variation. Landmark localization is accurate only if the
photogrammetry over direct surface anthropometry have landmarks occur directly on a contour line. Electromagnetic
been listed [79]. Contact of the anthropometric instruments digitizers and the detection of reflective markers by infrared
during direct measurement of soft tissue features may cameras record only the locations of specific landmarks
deform the facial surface and lead to inaccuracies. The same selected at the time of digitization and of marker placement,
landmarks used in several different measurements have to respectively. It is not possible to correct errors and redefine
be located repeatedly when direct measurements are made. the position of selected points or to locate additional points
The period of interaction with the patient is potentially at a later stage.
shorter for indirect measurements, since features are
measured after data acquisition. Indirect methods are 2.1. Stereo photogrammetry
therefore also less dependent on patient behavior and the
need for the patient to keep still for long periods, and have A 2D image may be regarded as a section through the
particular advantages when children are being examined. projections of object points in space. Because all space
Some measurements, such as those around the eyes, are points along a projection line will appear at the same point
difficult to obtain directly without risk of discomfort or on the image plane, a unique determination of the 3D
injury to the patient. Measurements based on soft tissue position in space corresponding to an object point in a 2D
landmarks might be more suited to photogrammetry, image is not possible. The introduction of additional images
while direct measurements would be preferable for bony allows a unique description of the object point as the
landmarks that require palpation [10]. intersection of two or more projections. This unique 3D
Single photogrammetry may be inadequate for description requires knowledge of the orientation of the
measurements of a 3D object such as the face. Tanner and cameras with respect to a common frame of reference.
Weiner [11] investigated single photogrammetry for body Camera calibration determines a mapping or set of
and face measurements, and found the greatest single source parameters that relate the 2D image position of an object
of error to be attributable to posing. Farkas [5] reported point to its corresponding 3D position in the reference
T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409 403

coordinate system. The mapping can be used to obtain the or by using image processing algorithms as will be
3D coordinates of points occurring on two or more 2D described later. In order to facilitate matching of the stereo
images. Two commonly used photogrammetric methods for images and 3D reconstruction of the face, texture may be
3D reconstruction of image points are the direct linear added in feature-poor areas such as the cheeks and forehead,
transformation [17] and bundle adjustment [18]. in the form of a random [25] or structured [4] light pattern.
Stereo-photogrammetry has been used on the face more The role of depth in facial measurements, and therefore
often than on any other part of the body [6] and was the utility of introducing stereo photogrammetry to
proposed for the examination of facial shape well before the eliminate the loss of depth information inherent in single
advent of digital imaging technology. In 1952, Zeller [19] photogrammetry, varies with the position of the facial
recorded a stereo pair of facial photographs in a stereometric feature being examined. Douglas et al. [27] compared the
camera and plotted contour maps of facial morphology in eye distance measurements used in screening children for
order to examine the soft tissues of the face. This technique fetal alcohol syndrome obtained from 2D photographs
entailed projection of stereo images onto a flat surface, with those obtained using stereo photogrammetry and found
fusion of these images into a 3D impression of the object in that, in an idealized system, where the real-world
the mind of the operator, positioning of a floating spot on coordinates of landmarks were known from 3D calibration
the surface of the object by the operator, and tracing of of stereo photographs, depth did not make a significant
depth contours of the object on paper, based on the position contribution to eye measurements. However, comparison of
of the floating spot [20]. Although a 3D record of the face measurements of single and stereo photogrammetry
was obtained in this manner, the distance intervals between revealed inaccuracies arising from misalignment of the
contours gave rise to inaccuracies and the equipment was camera, the face and the calibration instrument during
large and expensive. Despite efforts at improvement of this acquisition of single frontal photographs.
contour plotting technique [2022], it has had limited
clinical use [23]. 2.2. Image processing
Later stereo photogrammetric methods have obtained the
3D coordinates of feature points in stereo image pairs in Feature extraction methods applied to facial photographs
order to calculate distances between points [8,9,24], or have abound in the computer vision literature. Facial feature
achieved 3D reconstruction of the entire face [15,25]. extraction, particularly the extraction of eye and mouth
A stereo photogrammetric platform typically consists of features, and facial reconstruction are active research areas
two or more cameras which capture images of the subject for applications such as face tracking in video sequences,
simultaneously, or one or more cameras capturing images video compression, gesture recognition, secure systems and
sequentially with the subject remaining in the same pose. animation. The geometric relationship between the eyes,
The subjects face is surrounded by a calibration object or nose and mouth has been exploited for face and feature
placed in a space in which a calibration object was detection [28]. Facial features have been modeled by
previously imaged [9,15,24,25]. Fig. 1 shows the imaging deformable templates [29]. Eye and mouth center points
equipment used by Meintjes et al. [24]. Landmarks may be have been estimated using image templates [30].
selected manually by clicking a mouse on homologous Pupil centers have been detected with the aid of curvature
points on stereo images displayed on a computer monitor, functions [31]. Integral projections have been used for
determining the position of facial features [32]. Gaussian
mixture models of pixel color values have been used for lip
segmentation [33].
The success of such methods often depends on uniform
lighting conditions and the placement of initial estimates of
feature positions close to their actual positions in images.
Where cluttered images are being examined, feature
extraction usually follows face detection and rough
localization of the features in question, usually the eyes
and lips. For purposes of facial surface anthropometry,
facial photographs are usually taken under controlled
conditions, and preliminary estimations of feature positions
are possible, eliminating some of the preprocessing
required in other applications. Fig. 2 shows some surface
facial landmarks used in anthropometry that might, due to
their location on extremes of curves and contours,
be successfully extracted by image processing algorithms.
Fig. 1. Equipment for capturing stereo images, comprising two cameras Examples of facial image processing for surface
facing a chin- and headrest surrounded by calibration markers [24]. anthropometric applications follow.
404 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409

syndrome. Their method automatically identifies the pupil

centers, the endocanthion and the exocanthion. The contour
of the iris is extracted after a series of image processing
operations comprising peak and valley maps, integral
projection functions, extraction of connected components
and circle fitting. Eye contours are delineated by fitting
cubic splines to valley maps of the eyes with the aid of
genetic algorithms. The endpoints of the eye contour curves
represent the endocanthion and exocanthion, and the
centroids of the iris contours the pupil centers. Fig. 3
shows extracted eye contours, with underestimation of the
Fig. 2. Some surface landmarks that could potentially be identified endocanthion in some cases. The algorithm is fully
by image processing algorithms: enendocanthion; exexocanthion; automatic and rejects, without further processing, those
nnasion; pnpronasale; snsubnasale; lsmidpoint of upper vermi- images in which it is not possible to extract the iris.
lion line; limidpoint of lower vermilion line; chpoint at labial fissure;
The image processing methods described in Refs. [34,35]
were applied to 2D photographs. Souza et al. [34] found no
Souza et al. [34] developed a semi-automated algorithm statistically significant differences between manually traced
for detecting eyelid-related pathologies. The algorithm and computer-generated eyelid contours. Douglas et al. [35]
consists of preprocessing of images of the eye by a low used the direct linear transformation to obtain the 3D
pass filter, followed by the application of a Laplacian of coordinates of eye landmark positions automatically
Gaussian operator and a zero-crossing operator to yield an extracted from stereo images and subsequently measured
edge image in which an operator selects points on the upper palpebral fissure length, interpupillary distance, inner
eyelid contour. The software fits a second degree canthal distance (the distance between the endocanthi of
polynomial to the upper eyelid and allows measurement the right and left eye) and outer canthal distance
of the upper eyelid curvature, its horizontal displacement (the distance between the exocanthi of the right and left
relative to the palpebral fissure midline and its distance from eye). The automatically measured distances were compared
the pupil center, the palpebral fissure length, the angles of with those calculated after manual selection of points on the
and the height between the endocanthion and exocanthion, digital images. Mean differences between automatically
and the ratio between the temporal and nasal areas of the extracted and manual measurements were within 1 mm for
upper half of the palpebral fissure. The palpebral fissure is palpebral fissure length and interpupillary distance while
the eye cleft and its length is the distance between the maximum palpebral fissure length differences were greater
endocanthion and the exocanthion. Significant differences than 1 mm. Inaccuracies in the automatic method appeared
were found between curvatures from normal, blepharoptosis to occur most frequently due to underestimation of the
and Graves disease groups. endocanthion.
Douglas et al. [35] have explored a method of eye feature Cootes et al. [36] described active shape models to model
extraction to assist in the diagnosis of fetal alcohol the shape and appearance of variable objects, such as organs

Fig. 3. Automatically extracted eye contours (the right eye of four different subjects): (a) contours judged by visual inspection to be accurate; (b) contours
judged by visual inspection to underestimate the endocanthion [35].
T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409 405

and other features of interest in the human body, based on 40 images located within 2 mm at an 85% recognition rate.
the statistics of sets of labeled image examples of such Rudolph et al. [52] used spatial spectroscopy to identify 15
objects. A model consists of a shape template with cephalometric landmarks on 14 images and found no
constrained flexibility as well as a statistical description of statistical difference between manual and automatic
the gray level variation around each model point, and can be methods. Chen et al. [53] used neural networks and genetic
used to detect new instances of an object in images. Naftel algorithms to find sub-images containing required
et al. [37] combined active shape models for 3D facial landmarks. These three methods rely on the generation of
landmark extraction with geometrical shape analysis to a model of the gray levels around each point from a training
study 3D facial shape changes. Landmark points were set and subsequent matching of this model to a new image to
manually digitized in a training set of images. identify relevant points. This approach is limited by its
The Procrustes algorithm, which finds the optimal dependence on the reproducibility of the image appearance
alignment of configurations of landmark data, around each landmark across all images [49].
independently of translation, rotation and scaling [3840], The application of pattern matching only, in the absence
was used to compute a mean landmark pattern and a point of knowledge-based enhancements, can give rise to false
distribution model as well as a gray level appearance model detections far from the expected landmark location,
at each landmark point. Principal component analysis was reducing system accuracy [50].
carried out to obtain a set of basis vectors describing the The respective limitations of knowledge based and
main modes of shape variation in the training data. learning methods have led to combined approaches. Sanei
Locating landmarks in new images entailed using edge et al. [54] overcame the dependence on image quality and
detectors and integral projections to find facial borders local image appearance by using rule based fuzzy logic
based upon which the initial scale and pose of the face and based on known anatomical relationships and reported high
hence the initial estimates of landmark positions were accuracy for landmark location on cephalograms of both
determined, followed by an iterative search for the optimal adults and children. Hutton et al. [49] evaluated the use of
landmark positions. A stereo correlation matching active shape models for cephalometric landmark location
algorithm found homologous points in the second of the and concluded that their method was not sufficiently
stereo pair of images and 3D coordinates were calculated accurate for fully automated landmarking, but could be
using camera calibration parameters. Generalized used to provide initial landmark estimates. Grau et al. [50]
Procrustes analysis, principal component analysis and used knowledge-based edge detection to locate search areas
thin plate spline decomposition [39,41] were used to for landmarks, followed by template matching based on
distinguish between changes in facial morphology due to mathematical morphology [51], for exact location of
surgical treatment and changes due to other factors such as landmarks. The accuracy of the combined method exceeded
growth [37]. that of Cardillo and Sidahmed [51], which used only
pattern matching, with success rates ranging from 65 to
100%, and an overall success rate of 90.3% for all
3. Cephalometry landmarks. The combined method might be suitable for
routine clinical use if it included a landmark editing function
To date at least 20 independent researchers have [50]. Ciesielski et al. [42] used knowledge of facial
attempted automatic landmark identification from skull geometry to determine search areas for four facial
X-ray images or cephalograms with varying degrees of landmarks followed by genetic programming to evolve a
success and their research can be classified as using either program to find each landmark in its search region.
knowledge based methodologies or learning methodologies They found detection rates ranging from 63.9% (with
[42]. The former uses knowledge of the cranial structure 30.6% false alarm rate) to 100% (with 0% false alarm rate).
in image processing algorithms to identify landmarks.
Learning methodologies include artificial intelligence, 3.1. X-ray stereo photogrammetry
genetic programming and pattern matching approaches.
Several researchers have applied knowledge based 2D radiographs are characterized by distortion and
approaches to cephalometric landmark location [4347]. magnification due to the fanbeam geometry of the X-ray
Because these methods rely on rigid rules they are highly beam. These have to be corrected before quantitative
dependent on the quality of the input images, are unreliable analysis of the shapes captured in images is possible. Stereo
when image artifacts and structural anomalies are present, photogrammetry not only allows 3D reconstruction of
can only be applied to a small number of images conforming cephalometric landmarks from radiographs, but also
to the shape parameters encoded in the rules, and do not corrects distortion and magnification, resulting in 3D
favor the addition of new landmarks [42,4850]. coordinates that can be displayed graphically or used in a
Cardillo and Sidahmed [51] used pattern matching based variety of measurements.
on mathematical morphology to locate landmarks in Locating the spatial coordinates of points in stereo X-ray
cephalograms and were successful with 20 landmarks on images has been an area of interest since 1897, 2 years after
406 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409

Rontgen discovered X-rays, when images were viewed An interactive and a fully automatic image processing
through stereoscopes for visual 3D point localization [55], algorithm have been presented for the extraction of surface
and might have originated with the successful location of a facial landmarks used in syndrome diagnosis from 2D
metal object in the head [56,57]. The principles of X-ray images [34,35]. The rejection of unsuitable images by the
stereo photogrammetry are well known and are used in a automatic method and the underestimation of the
variety of medical applications [58]. Broadbent [59] endocanthion in some images might be avoided with
introduced 3D reconstruction of craniofacial landmarks the introduction of user interaction, yielding better accuracy
from stereo X-ray projections using orthogonal X-ray on a larger number of input images. The effect of infrared
sources. While the requirement for two X-ray sources and lighting during image acquisition on the clarity of facial
the difficulty of locating homologous points in both images features and hence the accuracy of feature extraction is
have impeded implementation [57,60], refinements of the worth investigating. Feature extraction directly from 3D
Broadbent [59] method have been described [61]. The use of facial models eliminates measurement errors associated
a single X-ray source to obtain stereo images for with the selection of corresponding points that are not truly
cephalometry in a digital X-ray imaging system has been homologous on stereo images. However, the construction of
proposed [58]. 3D models and the construction of 3D landmark coordinates
are subject to the same uncertainties of stereo image
matching, thus for simple applications requiring only
4. Discussion landmark data rather than more sophisticated information
such as volume or surface curvature, 3D landmark
In addition to cephalograms and photographs, X-ray coordinate construction might be more appropriate than
computed tomography (CT) and magnetic resonance 3D models.
imaging (MRI) have been used to obtain facial Once landmarks have been identified, further
morphology in three dimensions, and have the advantage investigation is possible with the aid of several shape
that both the surface and the underlying hard tissue can analysis methods which have to date been applied primarily
be captured [9,23,62]. They provide 3D visualization of to manually extracted landmarks, but which may be applied
the skull without any additional computational effort. to automatically or semi-automatically extracted landmarks.
However, these methods are relatively expensive and Procrustes methods, thin plate spline analysis and active
require co-operation from subjects during long scanning shape models have already been used on landmark data after
periods. In addition, CT exposes the subject to higher image processing. In addition, pattern profile analysis,
levels of ionizing radiation than does the acquisition of Euclidean distance matrix analysis, finite element modeling
planar X-ray images. Conventional X-rays have therefore and medial axis transformation belong to the set of shape
remained the standard for cephalometric imaging, analysis tools available for landmark data [40].
although multiplanar reconstruction computed tomogra- While landmarks are more difficult to locate manually in
phy (MPR-CT) is now used widely for preoperative cephalograms than in photographs, more image processing
mandibular examinations [63]. To date, image processing efforts have been aimed at cephalograms than at
and 3D landmark reconstruction from cephalograms have photographs, exploiting the presence of structurally mean-
been applied mostly to digitized radiographs. Direct ingful lines and edges and the absence of superficial
digital imaging would provide images that are more variations in appearance caused by hair and skin color in
easily manipulated, yielding more reliable results. cephalograms. The variations caused by the skeletal
Douglas et al. [58] have investigated 3D point localiza- deformities often analyzed on cephalograms would,
tion in low dose digital X-ray images, and found however, render fully automatic landmark extraction
accuracies consistent with those reported by others for difficult. Computer assisted methods have been used with
cephalometric studies. manual landmark location to calculate 3D coordinates in
X-ray cephalometry does not provide the natural cephalograms [57,60]. 3D methods in cephalometry have
appearance of the facial surface. The suitability of surface thus been limited to the reconstruction of landmarks from a
anthropometry for soft tissue landmarks and cephalometry small number of images and successful image processing
for bony landmarks suggests that both modalities should be for improved landmark extraction on 2D cephalograms
used for the planning of surgery in which the bony facial would lead to more efficient 3D methods.
structure is modified in order to alter surface appearance. Given the individual variations in craniofacial shape and
Ayoub et al. [23] achieved co-registration of cephalograms the high accuracies required for anthropometric data,
with 3D surface data obtained from photogrammetry maintaining a degree of user interaction in landmark
for simultaneous viewing of soft tissue and bone for identification algorithms, both for surface anthropometry
maxillofacial surgical planning. Such fusion of data and cephalometry, might serve the purpose of
from different medical image sources is an active simplifying the clinicians task while ensuring that accuracy
research area [64] and holds promise for the enhancement requirements are met. Fuzzy landmarks, obtained manually
of surgical planning. from CT images and an electromagnetic digitizer, have been
T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409 407

used to overcome difficulties in locating biological 5. Summary

structures occupying a larger area than a single point in
order to obtain information on the cranial surface [65]; Facial surface anthropometry and cephalometry have
image processing algorithms are well suited to and might be been used for many years for the diagnosis of
used for such fuzzy delineation. malformations, surgical planning and evaluation, and
Determining the accuracy of a feature extraction or growth studies. These disciplines rely on the identification
segmentation method is difficult in medical imaging, where of craniofacial landmarks and examine the geometric
no gold standard of measurement exists for the complex variation in the relative location or pattern of these
structures being examined. New measurement methods for landmarks in different individuals. Image processing
surface anthropometry are validated by comparison with algorithms applied to facial images have the potential to
direct measurements and their accuracy described in enhance anthropometric applications through reductions in
terms of their agreement with direct measurements. the time spent on examinations and improvements in the
Direct measurement using a ruler or calipers is subject to reliability of measurements, enabling automatic
errors of parallax, inter-operator variability and instrument- measurement of clinically relevant distances and angles,
dependent variability. Image processing methods can also as well as shape analysis and comparison. Stereo
be validated by comparing their results with those of manual photogrammetry has been used to obtain 3D coordinates
measurement on images displayed on a computer screen. of landmarks both from stereo photographs and stereo
In cephalometry, direct measurement is only possible on dry radiographs (cephalograms). Thanks to advances in imaging
skulls, and validation of image processing algorithms technology, surface anthropometry has been extended to the
relies on comparison with manual measurements from analysis of full 3D models of faces, although not routinely.
displayed images. The volumetric 3D extension of X-ray imaging, namely CT,
A difference of less than 1 mm between a new method is well established, but its cost and high dose of ionizing
and direct measurement in surface anthropometry is radiation have prevented its routine clinical use for
generally regarded as acceptable in published work [66]. cephalometry. Much research is therefore in progress to
The literature varies on the accuracy acceptable for optimize the extraction of useful cephalometric information
cephalometric landmarks: Rakosi [67] has suggested that from planar X-ray images. This paper reviews facial surface
an error of 2 mm is acceptable, while Forsyth [68] and anthropometry and cephalometry with reference to the
Richardson [69] have indicated that 1 mm is desirable. image processing algorithms that have been applied and
Although an error of 1 mm could result in a their effectiveness. Despite achievements in 3D reconstruc-
misclassification of a borderline case, such misclassification tion of landmarks in surface anthropometry and cephalo-
could be minimized by the use of fuzzy diagnostic borders metry, 3D modeling of complete faces, and the application
and the use of a combination of features for diagnosis. of sophisticated image processing algorithms, fully auto-
Comparison of the performance of image processing mated anthropometric systems have not been reported.
algorithms in terms of their accuracy in identifying a Individual variation in shape and distortions of the normal
particular landmark or measuring a particular feature is shape represented by malformations render automation
problematic when the algorithms are applied to images difficult, as in all areas of medical imaging. Also, and again
obtained using different image acquisition protocols that in common with other medical imaging applications, the
produce images of varying quality. In addition, the standard accuracy of image processing techniques in landmark
with which the results of image processing are compared extraction and measurement is hard to quantify.
should be reliable. The collection of normative
cephalometric data, other than from dry skulls and cadavers,
is hampered by ethical considerations in subjecting healthy
individuals to ionizing radiation. Normative data for
cephalometric studies do, however, exist [70,71].
This paper was written with the aid of a grant from
Normative data for surface anthropometry have primarily
the National Research Foundation in South Africa
been obtained by direct measurement. Systematic differ-
ences between anthropometric measurements derived from
calipers, rulers and photographs [72,73] highlight the need
for consistency in data collection methods when
measurements are compared. Farkas [66] emphasis on the
importance of the choice of instruments and technique in References
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Endod 2002;93(4):38293. Tania Douglas is a senior lecturer in the Department of Human Biology
[62] Kitai N, Kreiborg S, Murakami S, Bakke M, Moller ED, at the University of Cape Town. She holds a BSc in Electrical and
Darvann TAT, et al. A three-dimensional method of visualizing the Electronic Engineering from the University of Cape Town, an MS in
temporomandibular joint based on magnetic resonance imaging in a Biomedical Engineering from Vanderbilt University and a PhD in
case of juvenile chronic arthritis. Int J Paediatr Dent 2002;12(2): Bioengineering from the University of Strathclyde, and completed a
10915. postdoctoral fellowship at the Japan Broadcasting Corporation in Tokyo.
[63] Hanazawa T, Sano T, Seki K, Okano T. Radiologic measurements of Her current research projects include facial feature extraction for fetal
the mandible: a comparison between CT-reformatted and conven- alcohol syndrome screening, 3D point localization in low-dose X-ray
tional tomographic images. Clin Oral Implants Res 2004;15(2): images and image analysis to detect tuberculosis in sputum smears.