Digital Versus Manual Tracing in Cephalometric Analysis: A Systematic Review and Meta-Analysis

Abstract

Background: Over the years, various researchers have attempted to compare digital cephalometry with the conventional manual approach. There is a need to comprehensively analyze the findings from the earlier studies and determine the potential advantages and limitations of each method. The present systematic review aimed to compare the accuracy of digital and manual tracing in cephalometric analysis for the identification of skeletal and dental landmarks. Methods: A systematic search was performed using the keywords “Digital” AND “Manual” AND “Cephalometry” to identify relevant studies published in the English language in the past decade. The electronic data resources consulted for the elaborate search included the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE, PsycINFO, Scopus, ERIC, and ScienceDirect with controlled vocabulary and free text terms. Results: A total of n = 20 studies were identified that fulfilled the inclusion and exclusion criteria within the timeframe of 2013 to 2023. The data extracted from the included articles and corresponding meta-analyses are presented in the text. Conclusions: The findings of the present systematic review and meta-analysis revealed trends suggesting that digital tracing may offer reliable measurements for specific cephalometric parameters efficiently and accurately. Orthodontists must consider the potential benefits of digital cephalometry, including time-saving and user-friendliness.

Full text

J. Pers. Med. 2024, 14, 566. https://doi.org/10.3390/jpm14060566 www.mdpi.com/journal/jpm
Review
Digital Versus Manual Tracing in Cephalometric Analysis:
A Systematic Review and Meta-Analysis
Sameer Narkhede 1, Paritosh Rao 1, Veera Sawant 1, Sanpreet Singh Sachdev 2, Suraj Arora 3, Ajinkya M. Pawar 4,*,
Rodolfo Reda 5 and Luca Testarelli 5,*
1 Department of Orthodontics and Dentofacial Orthopedics, School of Dentistry, D.Y. Patil Deemed to Be
University, Navi Mumbai 400706, Maharashtra, India; sameer.narkhede@dypatil.edu (S.N.);
paritoshrao724@gmail.com (P.R.); veera.sawant@dypatil.edu (V.S.)
2 Department of Oral Pathology and Microbiology, Bharati Vidyapeeth (Deemed to Be University)
Dental College and Hospital, Navi Mumbai 400614, Maharashtra, India; sunpreetss@yahoo.in
3 Department of Restorative Dental Sciences, College of Dentistry, King Khalid University,
Abha 61421, Saudi Arabia; surajarorasgrd@yahoo.co.in
4 Department of Conservative Dentistry and Endodontics, Nair Hospital Dental College,
Mumbai 400034, Maharashtra, India
5 Department of Oral and Maxillo-Facial Science, Sapienza University of Rome,
Via Caserta 06, 00161 Rome, Italy; rodolfo.reda@uniroma1.it
* Correspondence: ajinkya@drpawars.com (A.M.P.); luca.testarelli@uniroma1.it (L.T.)
Abstract: Background: Over the years, various researchers have aempted to compare digital ceph-
alometry with the conventional manual approach. There is a need to comprehensively analyze the
ndings from the earlier studies and determine the potential advantages and limitations of each
method. The present systematic review aimed to compare the accuracy of digital and manual tracing
in cephalometric analysis for the identication of skeletal and dental landmarks. Methods: A sys-
tematic search was performed using the keywords “Digital” AND “Manual” AND “Cephalometry”
to identify relevant studies published in the English language in the past decade. The electronic data
resources consulted for the elaborate search included the Cochrane Central Register of Controlled
Trials (CENTRAL), MEDLINE, CINAHL, EMBASE, PsycINFO, Scopus, ERIC, and ScienceDirect
with controlled vocabulary and free text terms. Results: A total of n = 20 studies were identied that
fullled the inclusion and exclusion criteria within the timeframe of 2013 to 2023. The data extracted
from the included articles and corresponding meta-analyses are presented in the text. Conclusions:
The ndings of the present systematic review and meta-analysis revealed trends suggesting that
digital tracing may oer reliable measurements for specic cephalometric parameters eciently
and accurately. Orthodontists must consider the potential benets of digital cephalometry, includ-
ing time-saving and user-friendliness.
Keywords: orthodontics; cephalometry; skeletal malocclusion; articial intelligence
1. Introduction
Cephalometry is a valuable diagnostic tool used in dentistry to assess craniofacial
structures and aid in the diagnosis, treatment planning, and evaluation of orthodontic and
orthognathic cases [1]. This technique involves the analysis of cephalometric radiographs,
which provide detailed measurements and visual representations of the skull, jaws, and
soft tissues. The use of cephalometry in dentistry dates back to the early 20th century,
when researchers began to explore the relationship between facial structures and maloc-
clusions [2]. Over the years, cephalometric analysis techniques have evolved with ad-
vancements in imaging technology and the development of standardized landmarks and
measurements.
Citation: Narkhede, S.; Rao, P.;
Sawant, V.; Sachdev, S.S.; Arora, S.;
Pawar, A.M.; Reda, R.; Testarelli, L.
Digital Versus Manual Tracing in
Cephalometric Analysis: A
Systematic Review and Meta-
Analysis. J. Pers. Med. 2024, 14, 566.
hps://doi.org/10.3390/jpm14060566
Academic Editor: Achille Tarsitano
Received: 26 April 2024
Revised: 20 May 2024
Accepted: 23 May 2024
Published: 25 May 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Swierland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Aribution (CC BY) license
(hps://creativecommons.org/license
s/by/4.0/).

J. Pers. Med. 2024, 14, 566 2 of 23
Cephalometry plays a crucial role in various aspects of dentistry, particularly in or-
thodontics. It provides orthodontists with valuable information for accurate diagnosis,
treatment planning, and evaluation of treatment outcomes. By analyzing cephalometric
radiographs, clinicians can assess the skeletal and dental relationships, identify growth
paerns, and predict the potential for future growth.
There are two main types of cephalometric analysis: two-dimensional (2D) and three-
dimensional (3D) cephalometry. Two-dimensional cephalometry involves the analysis of
lateral cephalometric radiographs [3]. It provides measurements and visual representa-
tions of the craniofacial structures in two dimensions, allowing for the assessment of skel-
etal and dental relationships, as well as soft tissue proles. Three-dimensional cephalom-
etry utilizes advanced imaging techniques such as cone-beam computed tomography
(CBCT) to create three-dimensional models of the craniofacial complex [4]. This type of
analysis provides more detailed information about the spatial relationships of the struc-
tures, allowing for a more comprehensive assessment of the patient’s condition.
Cephalometric analysis relies on the identication of specic landmarks on the radi-
ographs and the measurement of various parameters. These landmarks can be categorized
into skeletal, dental, and soft tissue landmarks, each serving a specic purpose in the anal-
ysis [5,6]. The use of cephalometry for craniofacial assessment has been an integral part of
orthodontic practice [7–9]. Conventionally, the technique involves manual tracing of the
anatomical landmarks by superimposing transparent tracing papers on the lateral cepha-
lograms to geometrically calculate certain craniofacial measurements [10]. The method
has often been described as tedious, time-consuming, subjective, variable, and susceptible
to errors [11–13].
The reliance on manual tools and materials in traditional cephalometry signies
methodological consistency across studies. However, it is worth noting that this approach
is not without limitations. Manual tracing is inherently prone to inter-observer variability
and subjectivity, as dierent individuals may interpret and trace cephalograms with var-
ying degrees of precision [12,13]. The meticulous use of standardized tools helps mitigate
some of these challenges, but it remains essential to acknowledge the potential for human
error in manual cephalometric analyses.
Recent developments in digital technology in almost every eld have introduced a
new era in cephalometry [14]. The cephalometric analysis can now be performed using
computerized software that automatically identies and measures the anatomical land-
marks, thereby eciently providing more consistent assessments [6,15]. This minimizes
the scope of human error, observer bias, and the time required for analysis while improv-
ing the validity and reproducibility of the results [15,16].
Digital cephalometry, often facilitated by specialized software and electronic devices,
oers advantages such as increased eciency, reproducibility, and the potential for three-
dimensional analyses. The transition from manual to digital methods represents a para-
digm shift in cephalometric analysis, introducing the capability for automated landmark
identication and measurements, which may address some of the limitations associated
with manual tracing.
The contemporary landscape of cephalometric analysis has been signicantly inu-
enced by the proliferation of digital technologies, with various software applications play-
ing a pivotal role in facilitating precise and ecient assessments. The diverse range of
software utilized across the studies in this systematic review reects the evolving nature
of digital cephalometry and the exploration of dierent platforms to enhance diagnostic
capabilities.
Even so, it is equally important to critically evaluate the accuracy of the so-called
“automatic” cephalometric assessment, as it relies on the automatic detection of land-
marks by pre-trained software [16,17]. Over the years, various researchers have aempted
to compare digital cephalometry with the conventional manual approach. There is a need
to comprehensively analyze the ndings from the earlier studies and determine the po-
tential advantages and limitations of each method.

J. Pers. Med. 2024, 14, 566 3 of 23
In this context, the present systematic review aims to compare the accuracy of digital
and manual tracing in cephalometric analysis for the identication of skeletal and dental
landmarks. The review has the objectives of analyzing the current state of knowledge in
this domain and contributing to the ongoing evolution of digital cephalometry.
2. Materials and Methods
The present systematic review and meta-analysis were performed in accordance with
Preferred Reporting Items for Systematic Review 2020 (PRISMA 2020) [18,19], and the
protocol was registered in the PROSPERO database with reference ID: CRD42023452625
[20]. A systematic search was performed using the keywords “Digital” AND “Manual”
AND “Cephalometry” to identify relevant studies published in the English language in
the past decade (1 January 2013 to 31 July 2023). The electronic data resources consulted
for the elaborate search included the Cochrane Central Register of Controlled Trials (CEN-
TRAL), MEDLINE, CINAHL, EMBASE, PsycINFO, Scopus, ERIC, and ScienceDirect with
controlled vocabulary and free text terms.
2.1. Eligibility Criteria
Studies using manual tracing and digital tracing techniques for cephalometric anal-
ysis, irrespective of the software, were considered eligible for inclusion in the present re-
view. These included clinical trials, in vivo studies, randomized clinical trials, controlled
clinical trials, non-randomized clinical trials, quasi-experimental studies, non-experi-
mental studies, cohort studies, and cross-sectional studies. Only those studies with ceph-
alometric radiographs of good quality without any artifacts and having fully intact per-
manent central incisors and rst permanent molars and no craniofacial deformities were
included.
Studies involving cephalometric analysis of individuals with impacted teeth in the
anterior region, prosthetic restoration of the central incisors, previous orthodontic treat-
ment or orthognathic surgery, or cleft lip and palate syndromes were excluded from the
review. Review reports, case series, in vitro, animal studies, and single intervention stud-
ies without the comparative group were excluded. Figure 1 denotes the selection process
for the articles in the present systematic review.
2.2. Data Extraction
The author name, year, and country of the publication were recorded. The details
pertaining to the study design, including the study seings, sample size, sampling tech-
nique, and demographic characteristics of the samples, were noted. Details related to dig-
ital cephalometry include the amount of exposure, the magnication of the radiographs,
and the software used for cephalometric analysis.
The outcomes included either or all of the following outcomes using manual tracing
techniques as compared to digital tracing techniques for cephalometric analysis:
1. Angular measurements—SNA, SNB, ANB, IMPA, Interincisal angle, SN-MP, SN-PP,
MMA, and Gonial angle
2. Linear measurements were recorded—anterior cranial base (N-S), mandibular length
(Go-Me), maxillary length (ANS to PNS), and LAFH—lower anterior facial height.
(ANS to Me)
The conclusive ndings reported by the authors were also recorded.

J. Pers. Med. 2024, 14, 566 4 of 23
Figure 1. PRISMA ow diagram indicating the selection process of the articles in the present sys-
tematic review.
2.3. Data Reporting
The extracted qualitative data is planned to be reported primarily in the form of ta-
bles. The data concerning the temporal and geographical distribution of the studies has
been depicted in the form of bar charts and map charts, respectively. The quantitative data
and its subsequent meta-analysis have been narratively described, followed by a summa-
rized depiction in the form of forest plots.

J. Pers. Med. 2024, 14, 566 5 of 23
2.4. Assessments of the Risk of Bias and Quality
A simplied version of the NIH (National Institutes of Health) Quality Assessment
Tool for Observational Cohort and Cross-Sectional Studies was adopted to evaluate the
risk of bias and the methodological quality of the included papers, as they presented the
results of cross-sectional studies [21]. The judgment of “Unsure” was reported for the spe-
cic item of the questionnaire for which information was not available in the manuscript.
The quality of studies scoring more than ve out of eight “Yes” was considered “Good,”
the quality of studies that ranged from three to ve “Yes” was considered “Fair,” and the
quality of studies with less than three “Yes” was considered “Poor”.
2.5. Statistical Analysis for Quantitative Synthesis
Review Manager (RevMan) 5.3 was used for statistical analysis. Meta-analysis was
conducted on the studies that provided information on similar outcomes, irrespective of
the software used for digital tracing. The combined results were expressed as mean and
standard deviation for the continuous data at 95% condence intervals (CIs), and p < 0.05
was considered signicant. Chi-square and Tau-square were used to assess whether the
observed dierence was homogeneous or heterogeneous among the studies. Statistical
heterogeneity was assessed by the I2 test at α = 0.10. The I square statistic (I2) represents
the percentage of the variability in eect estimates that is due to heterogeneity. I2 is the
proportion of observed dispersion of results from dierent studies included in a meta-
analysis that is real rather than spurious.
Heterogeneity was considered statistically signicant if p < 0.05. For I2 > 50%, the
random-eects model was applied. Subgroup analysis was performed to reduce the
sources of clinical heterogeneity among the studies. Also, the statistical signicance was
set at a p-value (two-tailed) < 0.05. The detection of publication bias using funnel plots was
carried out for studies exceeding 10 in number for each outcome assessed.
3. Results
A total of n = 20 studies were identied fullling the inclusion and exclusion criteria
within the timeframe of 2013 to 2023 [22–41]. The year-wise distribution of these studies
is depicted in Figure 2. Findings from these studies are comprehensively summarized in
Table 1. All the studies were cross-sectional comparative studies that used digital cepha-
lometry as an intervention and manual tracing as a control. The quality assessment of all
the articles is summarized in Table 2.
Figure 2. Year-wise distribution of the studies.
0
1
2
3
4
5
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
Number of studies
Year

J. Pers. Med. 2024, 14, 566 6 of 23
Table 1. Characteristics and ndings of the studies included in the present systematic review.
Sr.
No.
Author and Year
of Study
Country
Sample
Size
Age Range
(in Years)
Gender
(M/F)
Software Used for
Digital Cephalometry
Comparator Technique Short Description
Conclusive Findings
1.
Navarro 2013 [22]
Brazil
50
NP
NP
Dolphin Imaging 11
program
i-Cat tomography
Conventional manual tracing
Digital cephalometry: Reliable, simi-
lar to manual tracing
2.
Goracci 2014 [23]
Italy
20
NP
NP
NemoCeph NX 2009
SmileCeph
Images rescaled to 1:1 using Adobe
Photoshop CS and printed on semi-gloss
paper on a clear acetate sheet placed over
printed images by lead pencil
Tablet-assisted cephalometry: Com-
parable to manual and PC-aided
methods; preferred when user-
friendliness and portability are prior-
itized
3.
Iacob 2014 [24]
Romania
60
8 to 23
22/38
Orthalis cephalometric
software
Manual tracing using a 0.5 mm pen on a
0.003-inch acetate paper on a light box, in a
dark room
Digital cephalometry: Accuracy akin
to manual technique
4.
Tanwani 2014
[25]
India
20
NP
NP
Dolphin imaging v
11.7.5.55
A sheet of lead acetate tracing paper meas-
uring 8 × 10-in and 0.003-in thickness on a
view box with the tracing paper positioned
over the radiograph with masking tape
Manual vs. digital tracings: Statisti-
cally signicant dierences in Bur-
stone and McNamara’s analyses
5.
Farooq 2016 [26]
India
44
17 to 30
NP
FACAD 3.6 software
Images resized to 1:1 scale using Adobe
Photoshop CS and printed on semi-gloss
paper.
Traced using a lead pencil on a clear acetate
sheet placed over printed images
Most of the commonly used measure-
ments made by digital cephalometry
were accurate
6.
Kamath 2016 [27]
India
20
NP
NP
FACAD software
Ilexis AB, Linköping,
Traced on a view box with acetate tracing
paper securely positioned over the radio-
graph with masking tape.
Manual and digital cephalometry
showed statistically signicant dier-
ences in the measurements obtained
on performing Steiner’s analysis
7.
Lindner 2016 [28]
Taiwan
400
7 to 76
mean:27
165/235
FALA system
Manual tracing
Digital cephalometry: Enhances clini-
cal workow eciency by rapidly
and accurately analyzing cephalo-
metric landmarks

J. Pers. Med. 2024, 14, 566 7 of 23
8.
Mahto 2016 [29]
India
50
NP
NP
AutoCEPH© version
1.0
Dolphin® imaging
software 11.7
Using a millimeter ruler and protractor
Digital cephalometry: Agreement
with manual tracing, suitable for
routine analysis
9.
Kasinathan 2017
[30]
India
50
NP
NP
Dolphin Imaging v
11.8
0.5 mm lead pencil on a 0.003 thickness ac-
etate sheet in a dark room over an X-ray
view box
Digital cephalometry: Similar results
to manual, with advantages in ar-
chiving and transmission
10.
Anuwongnukroh
2018 [31]
Thailand
108
NP
NP
Carestream Dental
V6.14
Manual tracing by overlaying acetate pa-
pers on lateral cephalograms
Digital cephalometry: Not as reliable
as manual, best used to support diag-
nosis
11.
Hassan 2019 [32]
Pakistan
110
18 to 38 mean:
23.43
44/66
TrophyDicom soft-
ware
Lead pencil in a dark room on an illumina-
tor.
Digital cephalometry: User-friendly,
time-saving alternative to manual
tracing
12.
Izgi 2019 [33]
Turkey
150
12 to 34
75/75
OnyxCeph V3.1.54
0.3 mm 2H lead pencil, a ruler, and a pro-
tractor on an A4 paper placed over the
printed image
Digital cephalometry: Preferred over
manual method
13.
Mohan 2021 [34]
India
20
18 to 32 mean:
22.4
20/20
OneCeph
0.3 mm lead pencil on a sheet of ne grade
36 μm mae acetate tracing paper taped
over the X-ray printout
Digital cephalometry: Reliable, fast,
and practical for clinical use
OneCeph is a simple, reliable,
accurate alternative to manual tracing
that saves clinical time and
armamentarium.
14.
Zamrik 2021 [35]
Turkey
30
NP
NP
OneCeph
Manual tracing using a 0.3 mm hard black
(HB) lead pencil
Digital vs. manual cephalometry:
Clinically insignicant dierences.
Both tracing methods reliable for
daily clinical practice.
15.
Katyal 2022 [36]
India
25
mean 18
14/11
WebCeph
FACAD
Digital images were imported to Adobe
Photoshop 7.0 and rescaled to 1:1, then
printed
Manually traced using a 0.35 mm lead
pencil
Digital cephalometry: Reliable, with
advantages of online AI-based soft-
ware (WebCeph) including cloud-
based storage, online archiving, quick
analysis, no need for specic installa-
tion or software, and compatibility
with any operating system.

J. Pers. Med. 2024, 14, 566 8 of 23
16.
Klinic 2022 [37]
Turkey
110
10 to 24 mean:
15.83
44/66
SATM CephNinja
V4.20
WebCeph
Manual tracing using a 0.3 mm hard black
lead pencil
Digital vs. manual cephalometry:
Statistically and clinically signicant
dierences
Digital cephalometry on
smartphones: Clearer image
perception, improved comfort
AI-based cephalometry: Promises
enhanced comfort, practicality, speed
17.
Salgado 2022 [38]
Mexico
42
7 to 19
mean:13
18/24
Cephalopoint
4H pencil, adhesive tape, protractor, ruler,
erasers, tracing paper, and negatoscope,
Digital cephalometry: One-third time
of manual tracing, ecient analysis
18.
Khan 2023 [39]
Pakistan
120
12 to 24 mean:
17.37
56/64
View Box V4.0
0.5 mm lead pencil and protractors on
0.003-inch mae acetate paper under a
standard view box
No signicant dierence: Manual vs.
digital cephalometry for selected an-
gular and linear measurements
19.
Khari 2023 [40]
India
100
NP
NP
WebCeph V15.0
FACAD
Manual tracing
AI-based tracing: Not yet ready to re-
place semi-automated computer-
aided methods
20.
Prince 2023 [41]
India
50
NP
NP
AutoCEPH©
The cephalograms were printed on 8 × 10-
in size radiographic lm using a compati-
ble X-ray printer.
WebCeph™ AI software: High agree-
ment with validated methods—Auto-
CEPH© and manual tracing.
NP = Not provided.

J. Pers. Med. 2024, 14, 566 9 of 23
Table 2. Methodological quality appraisal of included studies.
Study ID
Objective
Clearly
Stated?
Study
Population
Clearly
Defined?
Participation
Rate at
Least 50%?
Subjects
Comparable?
Justification of
Sample Size?
Reliability of
Outcome
Measures?
Assessors
Blinding?
Adjustment for
Confounders?
Quality of
Studies
Navarro 2013 [22]
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Good
Goracci 2014 [23]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Iacob 2014 [24]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Tanwani 2014 [25]
Yes
Yes
Unclear
Yes
No
Yes
Unclear
No
Fair
Farooq 2016 [26]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Kamath 2016 [27]
Yes
Yes
Unclear
Yes
No
Yes
No
No
Fair
Lindner 2016 [28]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Mahto 2016 [29]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Kasinathan 2017 [30]
Yes
Yes
Unclear
Yes
No
Yes
No
No
Fair
Anuwongnukro 2018 [31]
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Good
Hassan 2019 [32]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Izgi 2019 [33]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Mohan 2021 [34]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Zamrik 2021 [35]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Katyal 2022 [36]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Klinic 2022 [37]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good
Salgado 2022 [38]
No
Unclear
Yes
Unclear
No
Yes
No
No
Poor
Khan 2023 [39]
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
No
Good
Khattri 2023 [40]
Yes
Yes
Yes
Yes
No
Yes
Unclear
No
Good
Prince 2023 [41]
Yes
Yes
Yes
Yes
No
Yes
No
No
Good

J. Pers. Med. 2024, 14, 566 10 of 23
3.1. Narrative Synthesis
All studies were conducted in dierent parts of the world, with nine in India, three
in Turkey, two in Pakistan, and one study each in Taiwan, Brazil, Italy, Romania, Thailand,
and Mexico, respectively (Figure 3). All the included studies showed a cross-sectional
study design. Overall, 1559 subjects were included in this systematic review. Dierent
software was used for digital tracing of lateral cephalograms, such as NemoCeph, Smile-
Ceph, Orthalis, Dolphin Imaging, FACAD, FALA System, AutoCEPH, Carestream Dental,
TrophyDicom, OnyxCeph, OneCeph, SATM CephNinja, Cephalopoint, and View Box.
The sample size across the majority of studies ranged from 20 to 150, with the excep-
tion of the study by Lindner et al. [28], which comprised 400 subjects in the Taiwanese
population. All the Indian studies had a sample size of 20 to 50 subjects, except for Khari
et al. [40], who had a sample size of 100 subjects. Given the larger population size of India
as well as the ethnic diversity across its various states, it is essential to conduct studies
with relatively larger sample sizes across the dierent geographical areas to ensure that
the results obtained can be extrapolated to the general population.
Figure 3. Geographic distribution of the studies conducted across the various countries.
Since the age estimation methods are concerned with identifying the pubertal growth
spurt, most of the studies included age groups of patients that spanned across the pre-
pubertal, pubertal, and post-pubertal stages (n = 5). N = 4 studies used the age group of 18
to 32 for assessing the reliability of digital cephalometry in age assessment in young
adults, while Lindner et al. included populations of all age groups ranging from 7 to 76
years. The mean age of the subjects in all the studies, however, ranged from 13 to 27 years.

J. Pers. Med. 2024, 14, 566 11 of 23
The number of females was signicantly higher as compared to males in the majority
of the studies. This could be because females show a greater concern for orofacial esthetics
and, therefore, opt more commonly for orthodontic treatment as compared to males. Par-
ticularly, young females are the category of patients who most often apply for orthodontic
treatment, probably because of their higher aesthetic demands, despite their objective
needs being no greater. Manual tracing of cephalograms has always been performed using
lead acetate paper (0.03″) and a lead pencil, as noted across the various studies included
in the present systematic review. Additional equipment utilized in manual cephalometry
includes rulers, protractors, tapes, and other stationary.
In the present day, various softwares are available to perform digital cephalometric
analysis, which were utilized across the dierent studies included in the present system-
atic review. These included FACAD (n = 5), Dolphin (n = 4), Webceph (n = 3), AutoCeph
(n = 2), OneCeph (n = 2), NemoCeph, and SmileCeph. While the majority of the studies
compared digital cephalometry with manual tracing as a control, some authors also com-
pared two dierent softwares; for instance, one study compared Dolphin to AutoCeph,
and two studies compared WebCeph to FACAD [29,36,40]. With the advent of AI-based
software systems, recent investigators have tested and compared their utility against con-
ventional computer software [36,40,41]. These researchers found that while AI-based soft-
ware oers various advantages such as comfort, practicality, and speed, further research
is crucial before declaring them enough to replace the adequately tested computer soft-
ware.
When considering the conclusive ndings reported by the authors of the studies in-
cluded in the present systematic review, the majority found digital cephalometry more
preferable and reliable as compared to manual tracing, oering additional advantages
such as being reliable, rapid, accurate, user-friendly, time-saving, portable, and cloud-
based archiving. One author concluded that “the results obtained for manual and digital
were almost similar, but the digital landmark ploing has an added advantage in archiv-
ing, retrieval, and transmission and can be enhanced during the ploing of lateral cepha-
lograms [30].” Another study found tablet-based digital cephalometry to be equally relia-
ble as computer-based digital cephalometry and manual tracing [23]. Other n = 4 studies
also found digital cephalometry to have the same accuracy and reliability as the manual
method, suggesting that it can readily replace the conventional cephalometry technique.
Only one study performed in Thailand found that digital cephalometry was not as reliable
as manual analysis and that it should only be used to support a diagnosis rather than as a
sole diagnostic tool [31].
3.2. Meta-Analysis
A meta-analysis was performed to synthesize the ndings of the studies comparing
digital cephalometry to manual cephalometry. The data synthesis utilized both descrip-
tive and quantitative synthesis approaches to provide a comprehensive overview of the
studies included in this analysis.
3.2.1. Eect Measures
Eect measures are essential statistical constructs used to compare outcome data be-
tween two intervention groups. Examples include odds ratios and mean dierences,
which assess the odds of an event and the dierences in mean values between groups,
respectively. For this study, mean and standard deviation values were used as eect
measures.

J. Pers. Med. 2024, 14, 566 12 of 23
3.2.2. Study Inclusion
The meta-analysis incorporated data from a total of 14 studies. In a study conducted
by Mahato et al. in 2016 [29], two dierent software methods, AutoCEPH and Dolphin,
were utilized for digital tracing. For our quantitative assessment, data from both methods
were considered, and the study was subdivided into two distinct comparisons: Mahato
2016 (A) for AutoCEPH vs. manual tracing and Mahato 2016 (B) for Dolphin vs. manual
tracing.
3.2.3. Maxilla
1. SNA (Sella-Nasion-A Point): Our meta-analysis included data from twelve studies
for the assessment of SNA. The pooled SNA estimate was 0.54 (95% CI: −0.28 to 1.35),
suggesting that SNA values were greater with digital tracing compared to manual
tracing. However, the overall results were not statistically signicant (p > 0.05), and
there was substantial heterogeneity (65%), necessitating the use of a random eects
model for analysis.
2. Co-A (Cephalometric A Point): Our analysis incorporated data from ve studies for
Co-A measurements, resulting in a pooled value of 0.78 mm (95% CI: −1.37 to 2.94).
This indicates that Co-A measurements were greater with digital tracing compared
to manual tracing. Similarly, the overall results were not statistically signicant (p >
0.05), with a high level of heterogeneity (89%), leading to the application of a random
eects model.
3. Nperp-A (Nasion Perpendicular A): Our analysis included data from two studies for
Nperp-A measurements, resulting in a pooled value of −2.30 mm (95% CI: −4.11 to
−0.50), indicating that Nperp-A measurements were smaller with digital tracing com-
pared to manual tracing. Notably, the overall results were not statistically signicant
(p > 0.05), and heterogeneity was minimal (0%).
The forest plot for maxillary landmarks is depicted in Figure 4.
Figure 4. Forest plot for maxilla landmarks [22,25−27,29,31,33−37,39,41].

J. Pers. Med. 2024, 14, 566 13 of 23
3.2.4. Mandible
1. SNB (Sella-Nasion-B Point): Eleven studies were incorporated into the assessment of
SNB. The pooled SNB estimate was 0.26 (95% CI: −0.43 to 0.95), suggesting that SNB
values were greater with digital tracing compared to manual tracing. Nevertheless,
the overall results were not statistically signicant (p > 0.05), and there was a moder-
ate level of heterogeneity (39%), leading to the use of a random eects model for
analysis.
2. Co-Gn (Cephalometric Gnathion): Our analysis included data from ve studies for
the evaluation of Co-Gn measurements. The pooled Co-Gn estimate was −0.39 (95%
CI: −1.69 to 0.90), indicating that Co-Gn measurements were smaller with digital trac-
ing compared to manual tracing. The overall results were not statistically signicant
(p > 0.05), with a low level of heterogeneity (8%).
3. Pog-NB: Two studies were included in the assessment of Pog-NB. The pooled value
obtained was 2.91 [−3.58, 9.40], which was greater with digital tracing as compared
to manual tracing. Overall results were not statistically signicant (p > 0.05) with
100% heterogeneity. As a result, the random eects model was used for analysis.
4. FMPA: Eight studies were included in the assessment of FMPA. The pooled value
obtained was 0.62 [−0.54, 1.78], which was greater with digital tracing as compared
to manual tracing. Overall results were not statistically signicant (p > 0.05) with 50%
heterogeneity. As a result, the random eects model was used for analysis.
5. MIA: Two studies were included in the assessment of FMIA. The pooled mean dif-
ference value obtained was −0.28 [−2.92, 2.37], which was less with digital tracing as
compared to manual tracing. Overall results were not statistically signicant (p > 0.05)
with 0% heterogeneity.
6. Nperp-Pog: Two studies were included in the assessment of Nperp-Pog. The pooled
value obtained was −4.41 [−9.07, 0.26], indicating that Nperp-Pog was less with digital
tracing as compared to manual tracing. Overall results were not statistically signi-
cant (p > 0.05), with 24% heterogeneity.
The forest plot for mandibular landmarks is depicted in Figure 5.
3.2.5. Intermaxillary Relationships
1. ANB: Ten studies were included in the assessment of the ANB angle. The pooled
value obtained was −2.29 [−4.66, 0.06], indicating that ANB was lower with digital
tracing as compared to manual tracing. Overall results were not statistically signi-
cant (p > 0.05), with 97% heterogeneity. As a result, a random eects model was used
for analysis.
2. Wits appraisal: Four studies were included in the assessment of Wits appraisal. The
pooled value obtained was −0.28 [−1.08, 0.51]. This implies that the value of the Wits
appraisal obtained with digital tracing was less than manual tracing. Overall results
were not statistically signicant (p > 0.05) with 0% heterogeneity.
3. ANS-Me: Five studies were included in the assessment of ANS-Me landmark. The
pooled value obtained was 0.85 [−0.28, 2.28]. This implies that the value of ANS-Me
obtained with digital tracing was greater than that obtained with manual tracing.
Overall results were not statistically signicant (p > 0.05) with 55% heterogeneity. A
random eects model was used for analysis.
4. Jarabak ratio: Two studies were included in the assessment of the Jarabak ratio. The
pooled value obtained was −0.11 [−1.39, 1.18]. This implies that the value of the Ja-
rabak ratio obtained with digital tracing was less than that obtained with manual
tracing. Overall results were not statistically signicant (p > 0.05) with 0% heteroge-
neity.
The forest plot for intermaxillary relationships is depicted in Figure 6.

J. Pers. Med. 2024, 14, 566 14 of 23
Figure 5. Forest plot for mandible landmarks [22,25−27,29,31,33−37,39,41].

J. Pers. Med. 2024, 14, 566 15 of 23
Figure 6. Forest plot for intermaxillary relationships [22,25−27,29,31,33−37,39,41].
3.2.6. Dentoalveolar
1. U1-A point: Two studies were included in the assessment of the U1-A point land-
mark. The pooled value obtained was −0.24 [−0.73, 0.24], indicating that the value of
this landmark obtained with digital tracing was less as compared to manual tracing.
Overall results were not statistically signicant (p > 0.05), with 32% heterogeneity. As
a result, a random eects model was used for analysis.
2. LI-A Pog: Four studies were included in the assessment of the LI-A Pog landmark.
The pooled value obtained was −0.15 [−0.38–0.07], indicating that the value of this
landmark obtained with digital tracing was less as compared to manual tracing.
Overall results were not statistically signicant (p > 0.05), with 21% heterogeneity.
3. IMPA: Five studies were included in the assessment of the IMPA angle. The pooled
value obtained was −0.67 [−2.69, 1.34]. The value of this landmark obtained with dig-
ital tracing was less as compared to manual tracing. Overall results were not

J. Pers. Med. 2024, 14, 566 16 of 23
statistically signicant (p > 0.05) with 85% heterogeneity. As a result, a random eects
model was used for analysis.
4. UI-NA angle: Eight studies were included in the assessment of the UI-NA angle. The
pooled value obtained was −0.17 [−0.51–0.17] degrees, indicating that the value of this
landmark obtained with digital tracing was less as compared to manual tracing.
Overall results were not statistically signicant (p > 0.05), with 21% heterogeneity.
5. UI-NA (mm): Ten studies were included in the assessment of UI-NA distance. The
pooled value obtained was −0.09 [−0.52, 0.34]mm indicating that the value of this
landmark obtained with digital tracing was less as compared to manual tracing.
Overall results were not statistically signicant (p > 0.05) with 92% heterogeneity. As
a result, a random eects model was used for analysis.
6. LI-NB angle: Nine studies were included in the assessment of the LI-NB angle. The
pooled value obtained was −0.09 [−0.27, 0.08] degrees, indicating that the value of this
landmark obtained with digital tracing was less as compared to manual tracing.
Overall results were not statistically signicant (p > 0.05), with 43% heterogeneity. As
a result, a random eects model was used for analysis.
7. LI-NB (mm): Ten studies were included in the assessment of LI-NB distance. The
pooled value obtained was 0.10 [−0.12, 0.31]mm indicating that the value of this land-
mark obtained with digital tracing was greater as compared to manual tracing. Over-
all results were not statistically signicant (p > 0.05) with 70% heterogeneity. As a
result, a random eects model was used for analysis.
8. Go Gn to SN: Four studies were included in the assessment of the Go Gn to SN land-
mark. The pooled value obtained was 0.11 [−0.04, 0.27], indicating that the value of
this landmark obtained with digital tracing was greater as compared to manual trac-
ing. Overall results were not statistically signicant (p > 0.05) with 0% heterogeneity.
9. Nasolabial angle: Six studies were included in the assessment of the Nasolabial angle.
The pooled value obtained was 0.24 [−0.05, 0.53] degrees, indicating that the value of
this landmark obtained with digital tracing was greater as compared to manual trac-
ing. Overall results were not statistically signicant (p > 0.05), with 59% heterogene-
ity. As a result, a random eects model was used for analysis.
10. Interincisal angle: Three studies were included in the assessment of the interincisal
angle. The pooled value obtained was −0.03 [−0.27, 0.21] degrees, indicating that the
value of this landmark obtained with digital tracing was less as compared to manual
tracing. Overall results were not statistically signicant (p > 0.05) with 0% heteroge-
neity.
11. LAFH: Two studies were included in the assessment of the LAFH landmark. The
pooled value obtained was −0.51 [−1.36, 0.35], indicating that the value of this land-
mark obtained with digital tracing was less as compared to manual tracing. Overall
results were not statistically signicant (p > 0.05), with 73% heterogeneity. As a result,
a random eects model was used for analysis.
4. Discussion
The comprehensive review of 20 studies spanning the past decade provides valuable
insights into the comparative analysis of digital and manual cephalometry. Digital ceph-
alometry began to emerge in the late 20th century. While there is ambiguity regarding the
exact time of its introduction, it gained signicant traction in the 1980s and 1990s. It is
crucial to acknowledge the temporal dimension in the interpretation of ndings, as tech-
nological improvements and methodological renements may have occurred over this
time span. The recently introduced software has greater accuracy and reliability, and thus,
the present systematic review particularly selected the studies conducted in the past dec-
ade so that the ndings would be more relevant to the present-day scenario. This was
carried out to ensure that the reviewed evidence was of good quality with updated stand-
ards of research methodology and clinical practice.

J. Pers. Med. 2024, 14, 566 17 of 23
The geographical distribution of these studies reveals a notable concentration of re-
search in certain regions. Predominantly, the majority of studies emanated from India,
comprising nearly half of the total sample. This concentration may be aributed to various
factors, including the prevalence of cephalometric research initiatives, local expertise, and
regional healthcare priorities. The diversity in the geographical origin of studies, encom-
passing countries such as Turkey, Pakistan, Brazil, Italy, Taiwan, Thailand, and Mexico,
introduces a cross-cultural dimension to the analysis. Regional variations in diagnostic
practices, patient demographics, and available resources may contribute to nuanced nd-
ings and should be considered in the broader context of cephalometric research.
In assessing the implications of these ndings, it is essential to recognize that the
geographical distribution may inuence the generalizability of the results. Cephalometric
analyses are inherently sensitive to population-specic characteristics, and the prevalence
of certain anatomical variations or craniofacial features may dier across diverse popula-
tions. Consequently, the applicability of conclusions drawn from studies in one region to
a broader demographic should be approached with caution. Future research endeavors
should aim to foster a more globally representative body of literature to enhance the ex-
ternal validity of cephalometric ndings.
The observed variation in sample sizes across the reviewed studies ranged from 20
to 150 subjects, with a notable exception being one study with a substantial sample size of
400 subjects in the Taiwanese population [28]. The choice of sample size is a critical aspect
of study design and can signicantly inuence the statistical power and generalizability
of results [42]. The conventional wisdom in research design emphasizes the importance
of adequately powered studies to detect meaningful eects and enhance the external va-
lidity of ndings.
The relatively smaller sample sizes in the majority of Indian studies, ranging from 20
to 50 subjects, underscore a potential limitation in the representativeness of these ndings,
particularly given the vast and ethnically diverse population of India. Notably, the study
by Khari et al. [40] stands out with a larger sample size of 100 subjects. The decision to
adopt a larger sample size in this instance may reect an awareness of the need for in-
creased statistical power to draw robust conclusions, acknowledging the demographic in-
tricacies within India.
Given the larger population size and ethnic diversity across the various states of In-
dia, it is prudent to advocate for studies with relatively larger sample sizes conducted
across dierent geographical areas. This recommendation is rooted in the understanding
that a more expansive and diverse sample allows for a more reliable exploration of ceph-
alometric variations within the Indian population. The call for larger sample sizes is par-
ticularly relevant in the context of cephalometry, where subtle anatomical dierences may
exist across diverse ethnic groups.
The incorporation of diverse age groups in the evaluated studies underscores the
multifaceted nature of cephalometric analysis, particularly in the context of age estimation
methods aimed at identifying the pubertal growth spurt [43]. The inclusion of patients
spanning pre-pubertal, pubertal, and post-pubertal stages in a substantial number of stud-
ies (n = 5) aligns with the inherent focus on capturing the dynamic changes associated
with facial and craniofacial development during adolescence [44].
A subset of studies (n = 4) specically targeted young adults, utilizing the age group
of 18 to 32 years for assessing the reliability of digital cephalometry in age estimation. This
focused age range is strategically chosen to encompass the critical period of post-pubertal
growth and maturation, allowing for a detailed examination of cephalometric parameters
during this transitional phase. The decision to concentrate on young adults recognizes the
clinical relevance of age estimation in orthodontic and maxillofacial contexts, where the
assessment of skeletal maturity plays a pivotal role in treatment planning.

J. Pers. Med. 2024, 14, 566 18 of 23
The study by Lindner et al. [28] stands out for its inclusivity, encompassing popula-
tions of all age groups ranging from 7 to 76 years. This broad age spectrum is noteworthy
as it extends the applicability of digital cephalometry beyond the conventional focus on
adolescent and young adult populations. The inclusion of older individuals in cephalo-
metric studies addresses the potential impact of aging on craniofacial structures and pro-
vides insights into the utility of digital cephalometry across the entire lifespan. This com-
prehensive age representation is particularly relevant for clinical scenarios where cepha-
lometric analysis may be applied to individuals of varying ages.
Despite the diversity in the age groups studied, the mean age of subjects across all
included studies consistently ranged from 13 to 27 years. This convergence around a rel-
atively narrow age range reects a common emphasis on the critical period of facial
growth and development. The decision to focus on this age range may be driven by the
recognition that the pubertal growth spurt, a key aspect of age estimation, is most pro-
nounced during adolescence.
The observed predominance of females over males in the majority of the reviewed
studies raises intriguing considerations regarding gender distribution in cephalometric
research. The higher representation of females could be aributed to multifaceted factors,
with one plausible explanation being the heightened concern among females towards oro-
facial esthetics [45]. This inclination is consistent with existing literature suggesting that
females often exhibit a greater awareness of and emphasis on facial appearance and dental
aesthetics.
The phenomenon of a greater female representation in orthodontic studies aligns
with broader trends in healthcare-seeking behavior [46]. It is well documented that fe-
males tend to be more proactive in seeking orthodontic treatment, possibly due to their
heightened aesthetic awareness and societal expectations [47,48]. The perception of ortho-
dontic treatment as a means to enhance facial esthetics may contribute to the increased
prevalence of females in these studies. The observed gender disparity may reect not only
the prevalence of orthodontic issues among females but also their proactive approach to
addressing these concerns.
It is essential to acknowledge that the gender distribution in cephalometric studies
may introduce a potential bias in the generalizability of ndings. Cephalometric analyses
are inherently sensitive to gender-specic anatomical variations, and an overrepresenta-
tion of females may skew results towards characteristics more prevalent in that demo-
graphic. Consequently, the external validity of cephalometric conclusions, especially in
the context of treatment planning, should be interpreted with consideration for the gender
bias inherent in the available literature.
The consistent use of lead acetate paper (0.03″) and lead pencil in manual cephalom-
etry, as documented across the various studies included in this systematic review, high-
lights the traditional methods and materials employed in this technique. The utilization
of lead acetate paper with a specic thickness of 0.03″ speaks to the standardization and
precision required in manual tracing to ensure accurate cephalometric measurements
[10,49]. The tactile feedback and ease of marking provided by lead acetate paper contrib-
ute to the reliability of manual cephalometric tracings.
In addition to lead acetate paper and lead pencils, the mention of supplementary
equipment such as rulers, protractors, tapes, and other stationary items underscores the
meticulous nature of manual cephalometry [10,14]. These tools are essential for the precise
measurement of angles, distances, and anatomical landmarks on cephalograms. Rulers
and protractors aid in maintaining consistency in measurements, while tapes may be em-
ployed for linear assessments. The comprehensive set of stationary tools reects the thor-
ough approach required for manual cephalometric analysis, where even subtle deviations
in measurements can have clinical implications.

J. Pers. Med. 2024, 14, 566 19 of 23
Among the software applications mentioned, FACAD emerges as one of the most
frequently employed tools, with ve studies incorporating its use. Dolphin, Webceph, Au-
toCeph, and OneCeph also contribute to the digital cephalometric landscape, each being
utilized in multiple studies [22–41]. The choice of software may be inuenced by factors
such as user familiarity, interface capabilities, and specic features tailored to the require-
ments of cephalometric analysis [50].
Noteworthy is the comparative aspect of certain studies, where researchers have not
only contrasted digital cephalometry with manual tracing but have also directly com-
pared dierent software platforms [29,36,40]. These intra-digital software comparisons of-
fer valuable insights into the nuanced dierences between platforms and contribute to the
ongoing renement of digital cephalometric methodologies. The recent exploration of AI-
based software systems in cephalometric analysis marks a notable advancement in the
eld [36,40,41]. These studies acknowledge the advantages oered by AI-based tools, such
as increased comfort, practicality, and speed. The potential of AI to automate landmark
identication and streamline the analysis process represents a paradigm shift towards
more ecient and possibly more accurate cephalometric assessments.
However, the cautious stance adopted by researchers, emphasizing the need for fur-
ther research before considering AI-based software as a replacement for established com-
puter software, underscores the importance of rigorous validation and scrutiny in the in-
tegration of new technologies. The dynamic nature of cephalometric analysis, coupled
with the intricate nature of craniofacial anatomy, necessitates a thorough evaluation of the
capabilities and limitations of AI-based systems to ensure their reliability and clinical ap-
plicability.
The analysis of intermaxillary relationships provided insights into parameters that
assess the relative positions of the maxilla and mandible. The ANB angle, a signicant
indicator of anteroposterior jaw relationships, displayed lower values with digital tracing.
The pooled estimate of −2.29 was statistically signicant (p < 0.05), with high heterogeneity
(97%), indicating that digital tracing may provide more precise results for the ANB angle.
Wits appraisal, a parameter that helps in assessing the relationship between the maxilla
and mandible in three dimensions, demonstrated lower values with digital tracing, but
the overall results were not statistically signicant (p > 0.05). The lack of heterogeneity
(0%) within these studies suggests consistent outcomes for Wits appraisal measurements.
ANS-Me, which evaluates the vertical relationship of the maxilla and mandible, pre-
sented a trend with digital tracing yielding higher values, although the overall results
were not statistically signicant. The moderate heterogeneity (55%) within this group of
studies emphasizes the importance of considering variations in the software and meas-
urement techniques used for digital cephalometry. Conversely, the Jarabak ratio demon-
strated smaller values with digital tracing, and the results were not statistically signicant.
Furthermore, the heterogeneity was low (0%), implying consistent outcomes for this pa-
rameter between digital and manual tracing [51].
The meta-analysis provides an extensive evaluation of digital cephalometry com-
pared to manual tracing in orthodontics. The ndings suggest that digital tracing shows
promise in providing reliable measurements for specic cephalometric parameters. How-
ever, substantial heterogeneity among studies highlights the need for standardization in
software, techniques, and measurements. Further research is necessary to determine the
clinical signicance of these dierences and to beer guide the choice of tracing methods
in orthodontic practice. The potential benets of digital cephalometry in terms of time-
saving and user-friendliness should also be taken into account, as they may impact clinical
workow and patient care [52].
The collective ndings of the studies included in the systematic review present a
compelling argument in favor of digital cephalometry, with the majority of authors re-
porting it as more preferable and reliable compared to manual tracing. These conclusive
statements are supported by a spectrum of advantages aributed to digital cephalometry,
ranging from reliability and accuracy to practical benets such as speed, user-friendliness,

J. Pers. Med. 2024, 14, 566 20 of 23
portability, and cloud-based archiving. The recognition of digital cephalometry’s poten-
tial for enhancement during the ploing of lateral cephalograms suggests a transformative
role in streamlining workows and improving overall diagnostic eciency.
One study contributed to the consensus by nding tablet-based digital cephalometry
to be equally reliable as computer-based digital cephalometry and manual tracing [23].
This result underscores the versatility of digital cephalometry, as it extends beyond com-
puter-based platforms to accommodate emerging technologies like tablets. The equiva-
lence in reliability further supports the notion that digital cephalometry can be seamlessly
integrated into established diagnostic protocols.
Four additional studies, aligning with the overarching trend, report that digital ceph-
alometry exhibits equal accuracy and reliability as the manual method. This collective
sentiment echoes the idea that digital cephalometry has reached a level of maturity and
precision comparable to traditional manual tracing, suggesting its readiness for wide-
spread adoption in clinical practice. The implication is that digital cephalometry has the
potential to supplant conventional methods, oering a more ecient and technologically
advanced alternative.
It is noteworthy that the study in Thailand presents a dissenting perspective, noting
that digital cephalometry was not as reliable as manual analysis [31]. The cautious con-
clusion, suggesting that digital cephalometry should be used to support a diagnosis rather
than as a sole diagnostic tool, highlights the importance of considering regional and con-
textual variations in the adoption of new technologies. This dissenting view also under-
scores the need for ongoing research to address potential challenges and rene digital
cephalometric methodologies.
The limitations of our analysis include the heterogeneity in software, study design,
and sample characteristics, which may have inuenced the results. Future studies should
aim to address these limitations and provide more robust evidence on the advantages and
disadvantages of digital cephalometry in orthodontics. Nevertheless, our ndings suggest
that digital cephalometry has the potential to enhance clinical practice by oering con-
sistent and user-friendly alternatives to traditional manual tracing techniques.
5. Conclusions
The present meta-analysis compared digital cephalometry to manual cephalometry
in orthodontics, revealing trends suggesting that digital tracing may oer reliable meas-
urements for specic cephalometric parameters. Based on the comprehensive analysis of
twenty studies conducted between 2013 and 2023 comparing manual and digital cephalo-
metric tracing methods, our systematic review reveals varied outcomes across dierent
cephalometric landmarks. While digital tracing generally demonstrated increased meas-
urements for maxillary landmarks such as SNA and Co-A, the dierences were not statis-
tically signicant, indicating comparable accuracy to manual tracing. Conversely, man-
dibular landmarks, including SNB and Co-Gn, exhibited greater measurements with dig-
ital tracing, albeit without statistical signicance. Notably, some landmarks like Nperp-A
and Pog-NB displayed smaller measurements with digital tracing, though again lacking
statistical signicance. Moreover, intermaxillary relationships, as assessed by ANB and
Wits appraisal, showed trends towards smaller measurements with digital tracing, while
ANS-Me displayed larger measurements. Dentoalveolar landmarks exhibited mixed re-
sults, with some showing smaller measurements with digital tracing (e.g., U1-A point,
IMPA) and others displaying greater measurements (e.g., LI-NB distance, Go Gn to SN).
Importantly, none of the observed dierences reached statistical signicance, suggesting
that digital cephalometry, while oering potential advantages such as enhanced eciency
and reduced operator bias, does not signicantly alter measurement outcomes compared
to manual methods. Thus, both approaches remain valid options, and the choice between
them may depend on factors such as resource availability, expertise, and workow pref-
erences.

J. Pers. Med. 2024, 14, 566 21 of 23
However, substantial heterogeneity among studies highlights the need for standard-
ization in software, techniques, and measurements. Further research is required to deter-
mine the clinical signicance of these dierences and to beer guide the choice of tracing
methods in orthodontic practice. Additionally, orthodontists must consider the potential
benets of digital cephalometry, including time-saving and user-friendliness, and how
they may impact clinical workow and patient care. Despite the need for further explora-
tion and standardization, the potential of digital cephalometry to enhance clinical practice
is a promising development in the eld of orthodontics.
Author Contributions: Conceptualization, S.N., P.R., and V.S.; methodology, S.N., P.R., and V.S.;
software, S.S.S.; validation, S.N., L.T., R.R., S.A., and A.M.P.; formal analysis, S.N., P.R., and V.S.;
investigation, S.N., P.R., and V.S.; data curation, S.S.S.; writing—original draft preparation, S.N.,
P.R., S.A., and V.S.; writing—review and editing, A.M.P., S.S.S., L.T., and R.R.; visualization, S.N.;
supervision, A.M.P. All authors have read and agreed to the published version of the manuscript.
Funding: The authors extend their appreciation to the Deanship of Research and Graduate Studies
at King Khalid University, Abha, Saudi Arabia, for being supportive of this study through the Large
Research Group initiative, grant number (RGP2/469/45).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The data that supports the ndings of the present systematic review
are available within the article in the form of tables and forest plots.
Conicts of Interest: The authors declare no conicts of interest.
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