Conventional lateral cephalograms utilize two-dimensional (2D) technology, which limits the information retrieved from the scan. The accuracy and reliability with 3D superimpositions, offer a useful method for evaluating orthodontic treatment changes, as well as growth in patients. Cephalometric evaluation lacks a defined gold standard and Traditional methods face errors and time issues, while digital approaches vary in efficiency. This study aimed to evaluate and compare the accuracy of manual, digital and CBCT-generated superimposition of cephalometric landmarks.The study consisted of 20 patients wherein two lateral cephalograms and two CBCT were taken for each patient. They were traced manually/digitally at the beginning and one-year intervals. Reference landmarks marked on the anterior cranial base, maxilla, and mandible for superimposition of radiographs and CBCT. Radiographic tracings were superimposed manually, digital superimposition done with DOLPHIN software for radiographs and INVIVO SOFTWARE for CBCT scans. Subsequently, these superimpositions were compared for accuracy.Maxillary and mandibular measurements showed improved 3D accuracy over manual and 2D methods in both the X and Y axes. Dentition measurements significantly improved in 2D and 3D compared to manual. Soft tissue measurements in 3D surpassed both manual and 2D, with no significant difference from 2D for mean soft tissue measurements.Compared to manually and digitally traced radiographs, all evaluated procedures were acceptable and dependable. The CBCT scans provided higher levels of accuracy and reliability.
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