In vivo comparison of MRI- and CBCT-based 3D cephalometric analysis: beginning of a non-ionizing diagnostic era in craniomaxillofacial imaging?

  • Alexander Juerchott
  • Christian Freudlsperger
  • Dorothea Weber
  • Johann M. E. Jende
  • Muhammad Abdullah Saleem
  • Sebastian Zingler
  • Christopher J. Lux
  • Martin Bendszus
  • Sabine Heiland
  • Tim HilgenfeldEmail author
Head and Neck



To evaluate whether magnetic resonance imaging (MRI) can serve as an alternative diagnostic tool to the “gold standard” cone-beam computed tomography (CBCT) in 3D cephalometric analysis.


In this prospective feasibility study, 12 patients (8 males, 4 females; mean age ± SD, 26.1 years ± 6.6) underwent 3D MRI and CBCT before orthognathic surgery. 3D cephalometric analysis was performed twice by two independent observers on both modalities. For each dataset, 27 cephalometric landmarks were defined from which 35 measurements (17 angles, 18 distances) were calculated. Statistical analyses included the calculation of Euclidean distances, intraclass correlation coefficients (ICCs), Bland-Altman analysis, and equivalence testing (linear mixed effects model) with a predefined equivalence margin of ± 1°/1 mm.


Analysis of reliability for CBCT vs. MRI (intra-rater I/intra-rater II/inter-rater) revealed Euclidean distances of 0.86/0.86/0.98 mm vs. 0.93/0.99/1.10 mm for landmarks, ICCs of 0.990/0.980/0.986 vs. 0.982/0.978/0.980 for angles, and ICCs of 0.992/0.988/0.989 vs. 0.991/0.985/0.988 for distances. Bland-Altman analysis showed high levels of agreement between CBCT and MRI with bias values (95% levels of agreement) of 0.03° (− 1.49; 1.54) for angles and 0.02 mm (− 1.44; 1.47) for distances. In the linear mixed effects model, the mean values of CBCT and MRI measurements were equivalent.


This feasibility study indicates that MRI enables reliable 3D cephalometric analysis with excellent agreement to corresponding measurements on CBCT. Thus, MRI could serve as a non-ionizing alternative to CBCT for treatment planning and monitoring in orthodontics as well as oral and maxillofacial surgery.

Key Points

• Clinically established 3D cephalometric measurements performed on MRI are highly reliable and show an excellent agreement with CBCT (gold standard).

• The MRI technique applied in this study could be used as a non-ionizing diagnostic tool in orthodontics as well as oral and maxillofacial surgery.

• Since most patients benefiting from 3D cephalometry are young in age, the use of MRI could substantially contribute to radiation protection and open up new possibilities for treatment monitoring.


Magnetic resonance imaging Cone-beam computed tomography Orthodontics Orthognathic surgery Oral and maxillofacial surgeons 







Cone-beam computed tomography


Confidence interval


Field of view


Intraclass correlation coefficient


Magnetic resonance imaging


Multiple slab acquisition with view angle tilting


Sampling perfection with application optimized contrasts using different flip angle evolution



We thank the Dietmar Hopp Foundation for their generous support of this research project and Mathias Nittka from Siemens Healthcare for his cooperation and assistance in the setup of the MSVAT-SPACE sequence.

Funding information

This work was supported by a grant from the Dietmar Hopp Foundation (grant number: 23011228; grant holders: AJ, SH, SZ, CJL). AJ receives funding from a postdoctoral fellowship of the Medical Faculty of the University of Heidelberg.

Compliance with Ethical Standards


The scientific guarantor of this publication is Tim Hilgenfeld.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise (Dorothea Weber).

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• prospective

• diagnostic or prognostic study

• performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Alexander Juerchott
    • 1
  • Christian Freudlsperger
    • 2
  • Dorothea Weber
    • 3
  • Johann M. E. Jende
    • 1
  • Muhammad Abdullah Saleem
    • 4
  • Sebastian Zingler
    • 5
  • Christopher J. Lux
    • 5
  • Martin Bendszus
    • 1
  • Sabine Heiland
    • 4
  • Tim Hilgenfeld
    • 1
    Email author
  1. 1.Department of NeuroradiologyHeidelberg University HospitalHeidelbergGermany
  2. 2.Department of Oral and Maxillofacial SurgeryHeidelberg University HospitalHeidelbergGermany
  3. 3.Institute of Medical Biometry and Informatics (IMBI)Heidelberg University HospitalHeidelbergGermany
  4. 4.Section of Experimental Radiology, Department of NeuroradiologyHeidelberg University HospitalHeidelbergGermany
  5. 5.Department of Orthodontics and Dentofacial OrthopaedicsHeidelberg University HospitalHeidelbergGermany

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