Effect of CBCT-based root visualization on virtual bracket placement in a CAD/CAM indirect bonding workflow

The adoption of indirect bonding in orthodontics has grown substantially in recent years. The incorporation of a computer-aided design/computer-aided manufacturing (CAD/CAM) approach can improve bracket positioning precision and potentially reduce treatment time. Additionally, cone-beam computed tomography (CBCT) enables three-dimensional evaluation of both crowns and roots, and the integration of digital models with CBCT data may enhance the precision of the indirect bonding process. This study aims to evaluate the precision of bracket placement in indirect bonding, with and without the superimposition of CBCT images onto digital models, as performed by orthodontists. A total of 22 orthodontists participated in this study. Each orthodontist performed virtual bonding on digital models using OrthoAnalyzer™ software (3Shape A/S, Copenhagen, Denmark) in two stages: first, visualizing only the clinical crowns, and after a minimum interval of 15 days, visualizing both the crowns and roots with the aid of CBCT images. Bracket positioning discrepancies between the two bonding sessions were measured to assess intra-operator consistency. Positional deviations were analyzed in three dimensions: vertical, horizontal, and angular. Statistical analysis was conducted at a significance level of 5%. Positional deviations were within clinically acceptable limits for both horizontal and vertical dimensions, with deviations measuring less than 0.5 mm. However, angular deviations exceeded the clinically acceptable threshold of 2° for certain dental elements. The results indicate that orthodontists maintained consistent precision in the vertical and horizontal dimensions. However, the integration of CBCT data affected the precision of angular measurements. These findings suggest that incorporating CBCT into the indirect bonding workflow alters bracket placement in certain angular dimensions for specific teeth, which is critical for achieving optimal orthodontic outcomes.