Computerized Medical Imaging and Graphics 28 (2004) 401409

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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

Abstract
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
effectiveness.
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

Anthropometry provides objective means to assess facial
shape and detect shape changes over time, in order to
diagnose genetic and acquired malformations, to plan and
evaluate surgery, to study normal and abnormal growth and
to differentiate between the results of treatment and normal
growth. While the term anthropometry covers measurement
of any aspect of the human form, the term surface
anthropometry is used in this paper to refer to the
measurement of surface features, while cephalometry
refers to the analysis of craniofacial features from X-ray
images of the head, or cephalograms.
Surface anthropometry for the assessment of facial
features in dysmorphic patients was first used for facial
clefts and now provides a quantitative basis for pattern
recognition and syndrome diagnosis [1], through the
establishment of firm diagnostic criteria as well as the
demonstration of the range of variability of expression of
any given syndrome [2]. Cephalometry is widely used to
study the bony structure of the face for diagnosis, treatment
* Tel.: C27-21-406-6541; fax: C27-21-448-7226.
E-mail address: tdouglas@cormack.uct.ac.za.
0895-6111/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.compmedimag.2004.06.002
prediction and monitoring.
Anthropometric and cephalometric studies are based on
biological homology, i.e. spatial correspondence between
definable points on structures in individuals, and geometric
variation in the relative location or pattern of these points or
landmarks [3]. Craniofacial form is defined by size and
shape, and both are analyzed. Quantitatively determining
the extent of deviation of an individuals facial pattern from
the normal state requires the collection of data on normal
individuals in order to establish numerical descriptions of
normal measurement ranges. Syndrome diagnosis requires
the definition of characteristic abnormal patterns associated
with a given syndrome. Growth studies require facial
pattern changes to be monitored over time. Surgical
planning requires visualization and quantification of
dysmorphic features and the ability to model the changes
that surgery is expected to bring about.
Image processing algorithms applied to facial images
have the potential to enhance anthropometric applications
through reductions in the time spent on examinations and
improvements in the reliability of measurements. Automatic
extraction of desired facial features or landmarks would
enable automatic measurement of clinically relevant
402 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409
distances and angles, as well as shape analysis and
comparison. This paper reviews landmark localization
from facial photographs and cephalograms, concentrating
on those methods that have used image processing
algorithms to provide a degree of automation; many
interesting applications of surface anthropometry and
cephalometry which have not been enhanced by image
processing, are therefore not covered here.
2. Photogrammetry
Facial measurement from photographs as an alternative
to direct measurement using instruments such as rulers or
calipers has been introduced both in 2D and 3D
applications. Photogrammetry is the process of obtaining
measurements by means of photographs, while stereo
photogrammetry refers to the special case, where two or
more cameras are used to obtain 3D information of a scene.
In line with these definitions, the term photogrammetry,
when used by anthropometrists, has generally referred to
measurement from photographs [1,4,5]. However, in the
fields of research concerned with imaging of architectural
and geological structures (e.g. remote sensing and
geomatics), photogrammetry is often used to refer to 3D
reconstruction from 2D images; when researchers from
these fields have transferred their techniques to medical
applications, their usage of the term has persisted [6]. In this
paper, the term stereo photogrammetry will be used to
indicate the derivation of 3D information of objects from
their 2D images, while single or 2D photogrammetry will
refer to measurement from single photographs.
Several advantages of indirect methods such as
photogrammetry over direct surface anthropometry have
been listed [79]. Contact of the anthropometric instruments
during direct measurement of soft tissue features may
deform the facial surface and lead to inaccuracies. The same
landmarks used in several different measurements have to
be located repeatedly when direct measurements are made.
The period of interaction with the patient is potentially
shorter for indirect measurements, since features are
measured after data acquisition. Indirect methods are
therefore also less dependent on patient behavior and the
need for the patient to keep still for long periods, and have
particular advantages when children are being examined.
Some measurements, such as those around the eyes, are
difficult to obtain directly without risk of discomfort or
injury to the patient. Measurements based on soft tissue
landmarks might be more suited to photogrammetry,
while direct measurements would be preferable for bony
landmarks that require palpation [10].
Single photogrammetry may be inadequate for
measurements of a 3D object such as the face. Tanner and
Weiner [11] investigated single photogrammetry for body
and face measurements, and found the greatest single source
of error to be attributable to posing. Farkas [5] reported
consistent errors in some facial distances obtained from 2D
photogrammetry; only 20 of 60 measurements from
photographs showed acceptable values when compared
with direct measurements. The 2D nature of prints as well as
landmarks that were not visible or obscured by hair
prevented the measurement of 40 features from
single photographs out of 100 that are available using
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
measured from frontal photographs was necessary in order
to compensate for the loss of depth information. Ratios of
facial distances, angles and triangles connecting landmark
points obtained from photographs have been used as proxy
measures for absolute distances, where photographs lacked
internal measures of scale [4,13,14].
Methods of capturing 3D surface facial structure without
the use of photographs include laser surface scanning [15],
Moire topography and contour photography [9], the use of
electromagnetic digitizers [16] and the detection of
reflective markers by infrared cameras [8].
Laser scanning utilizes low-power laser beams, projected
onto the face while the subject is rotated with respect to the
beams, and viewed from an oblique angle by a video
camera. It requires a set facial expression during a scanning
period of several seconds and does not capture surface
texture. Both Moire topography and contour photography
project grids onto the subject resulting in contour lines on
the pictures from which the 3D coordinates of points are
determined. These methods are well suited to the capture of
gently curving surfaces such as the human back but result in
sparse facial data on features with high levels of depth
variation. Landmark localization is accurate only if the
landmarks occur directly on a contour line. Electromagnetic
digitizers and the detection of reflective markers by infrared
cameras record only the locations of specific landmarks
selected at the time of digitization and of marker placement,
respectively. It is not possible to correct errors and redefine
the position of selected points or to locate additional points
at a later stage.
2.1. Stereo photogrammetry
A 2D image may be regarded as a section through the
projections of object points in space. Because all space
points along a projection line will appear at the same point
on the image plane, a unique determination of the 3D
position in space corresponding to an object point in a 2D
image is not possible. The introduction of additional images
allows a unique description of the object point as the
intersection of two or more projections. This unique 3D
description requires knowledge of the orientation of the
cameras with respect to a common frame of reference.
Camera calibration determines a mapping or set of
parameters that relate the 2D image position of an object
point to its corresponding 3D position in the reference
 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409
coordinate system. The mapping can be used to obtain the
3D coordinates of points occurring on two or more 2D
images. Two commonly used photogrammetric methods for
3D reconstruction of image points are the direct linear
transformation [17] and bundle adjustment [18].
Stereo-photogrammetry has been used on the face more
often than on any other part of the body [6] and was
proposed for the examination of facial shape well before the
advent of digital imaging technology. In 1952, Zeller [19]
recorded a stereo pair of facial photographs in a stereometric
camera and plotted contour maps of facial morphology in
order to examine the soft tissues of the face. This technique
entailed projection of stereo images onto a flat surface,
fusion of these images into a 3D impression of the object in
the mind of the operator, positioning of a floating spot on
the surface of the object by the operator, and tracing of
depth contours of the object on paper, based on the position
of the floating spot [20]. Although a 3D record of the face
was obtained in this manner, the distance intervals between
contours gave rise to inaccuracies and the equipment was
large and expensive. Despite efforts at improvement of this
contour plotting technique [2022], it has had limited
clinical use [23].
Later stereo photogrammetric methods have obtained the
3D coordinates of feature points in stereo image pairs in
order to calculate distances between points [8,9,24], or have
achieved 3D reconstruction of the entire face [15,25].
A stereo photogrammetric platform typically consists of
two or more cameras which capture images of the subject
simultaneously, or one or more cameras capturing images
sequentially with the subject remaining in the same pose.
The subjects face is surrounded by a calibration object or
placed in a space in which a calibration object was
previously imaged [9,15,24,25]. Fig. 1 shows the imaging
equipment used by Meintjes et al. [24]. Landmarks may be
selected manually by clicking a mouse on homologous
points on stereo images displayed on a computer monitor,
Fig. 1. Equipment for capturing stereo images, comprising two cameras
facing a chin- and headrest surrounded by calibration markers [24].
403
or by using image processing algorithms as will be
described later. In order to facilitate matching of the stereo
images and 3D reconstruction of the face, texture may be
added in feature-poor areas such as the cheeks and forehead,
in the form of a random [25] or structured [4] light pattern.
The role of depth in facial measurements, and therefore
the utility of introducing stereo photogrammetry to
eliminate the loss of depth information inherent in single
photogrammetry, varies with the position of the facial
feature being examined. Douglas et al. [27] compared the
eye distance measurements used in screening children for
fetal alcohol syndrome obtained from 2D photographs
with those obtained using stereo photogrammetry and found
that, in an idealized system, where the real-world
coordinates of landmarks were known from 3D calibration
of stereo photographs, depth did not make a significant
contribution to eye measurements. However, comparison of
measurements of single and stereo photogrammetry
revealed inaccuracies arising from misalignment of the
camera, the face and the calibration instrument during
acquisition of single frontal photographs.
2.2. Image processing
Feature extraction methods applied to facial photographs
abound in the computer vision literature. Facial feature
extraction, particularly the extraction of eye and mouth
features, and facial reconstruction are active research areas
for applications such as face tracking in video sequences,
video compression, gesture recognition, secure systems and
animation. The geometric relationship between the eyes,
nose and mouth has been exploited for face and feature
detection [28]. Facial features have been modeled by
deformable templates [29]. Eye and mouth center points
have been estimated using image templates [30].
Pupil centers have been detected with the aid of curvature
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.
Examples of facial image processing for surface
anthropometric applications follow.
404 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409
Fig. 2. Some surface landmarks that could potentially be identified
by image processing algorithms: enendocanthion; exexocanthion;
nnasion; pnpronasale; snsubnasale; lsmidpoint of upper vermi-
lion line; limidpoint of lower vermilion line; chpoint at labial fissure;
gngnathion.
Souza et al. [34] developed a semi-automated algorithm
for detecting eyelid-related pathologies. The algorithm
consists of preprocessing of images of the eye by a low
pass filter, followed by the application of a Laplacian of
Gaussian operator and a zero-crossing operator to yield an
edge image in which an operator selects points on the upper
eyelid contour. The software fits a second degree
polynomial to the upper eyelid and allows measurement
of the upper eyelid curvature, its horizontal displacement
relative to the palpebral fissure midline and its distance from
the pupil center, the palpebral fissure length, the angles of
and the height between the endocanthion and exocanthion,
and the ratio between the temporal and nasal areas of the
upper half of the palpebral fissure. The palpebral fissure is
the eye cleft and its length is the distance between the
endocanthion and the exocanthion. Significant differences
were found between curvatures from normal, blepharoptosis
and Graves disease groups.
Douglas et al. [35] have explored a method of eye feature
extraction to assist in the diagnosis of fetal alcohol
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].
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
endocanthion in some cases. The algorithm is fully
automatic and rejects, without further processing, those
images in which it is not possible to extract the iris.
The image processing methods described in Refs. [34,35]
were applied to 2D photographs. Souza et al. [34] found no
statistically significant differences between manually traced
and computer-generated eyelid contours. Douglas et al. [35]
used the direct linear transformation to obtain the 3D
coordinates of eye landmark positions automatically
extracted from stereo images and subsequently measured
palpebral fissure length, interpupillary distance, inner
canthal distance (the distance between the endocanthi of
the right and left eye) and outer canthal distance
(the distance between the exocanthi of the right and left
eye). The automatically measured distances were compared
with those calculated after manual selection of points on the
digital images. Mean differences between automatically
extracted and manual measurements were within 1 mm for
palpebral fissure length and interpupillary distance while
maximum palpebral fissure length differences were greater
than 1 mm. Inaccuracies in the automatic method appeared
to occur most frequently due to underestimation of the
endocanthion.
Cootes et al. [36] described active shape models to model
the shape and appearance of variable objects, such as organs
 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409
and other features of interest in the human body, based on
the statistics of sets of labeled image examples of such
objects. A model consists of a shape template with
constrained flexibility as well as a statistical description of
the gray level variation around each model point, and can be
used to detect new instances of an object in images. Naftel
et al. [37] combined active shape models for 3D facial
landmark extraction with geometrical shape analysis to
study 3D facial shape changes. Landmark points were
manually digitized in a training set of images.
The Procrustes algorithm, which finds the optimal
alignment of configurations of landmark data,
independently of translation, rotation and scaling [3840],
was used to compute a mean landmark pattern and a point
distribution model as well as a gray level appearance model
at each landmark point. Principal component analysis was
carried out to obtain a set of basis vectors describing the
main modes of shape variation in the training data.
Locating landmarks in new images entailed using edge
detectors and integral projections to find facial borders
based upon which the initial scale and pose of the face and
hence the initial estimates of landmark positions were
determined, followed by an iterative search for the optimal
landmark positions. A stereo correlation matching
algorithm found homologous points in the second of the
stereo pair of images and 3D coordinates were calculated
using camera calibration parameters. Generalized
Procrustes analysis, principal component analysis and
thin plate spline decomposition [39,41] were used to
distinguish between changes in facial morphology due to
surgical treatment and changes due to other factors such as
growth [37].
3. Cephalometry
To date at least 20 independent researchers have
attempted automatic landmark identification from skull
X-ray images or cephalograms with varying degrees of
success and their research can be classified as using either
knowledge based methodologies or learning methodologies
[42]. The former uses knowledge of the cranial structure
in image processing algorithms to identify landmarks.
Learning methodologies include artificial intelligence,
genetic programming and pattern matching approaches.
Several researchers have applied knowledge based
approaches to cephalometric landmark location [4347].
Because these methods rely on rigid rules they are highly
dependent on the quality of the input images, are unreliable
when image artifacts and structural anomalies are present,
can only be applied to a small number of images conforming
to the shape parameters encoded in the rules, and do not
favor the addition of new landmarks [42,4850].
Cardillo and Sidahmed [51] used pattern matching based
on mathematical morphology to locate landmarks in
cephalograms and were successful with 20 landmarks on
405
40 images located within 2 mm at an 85% recognition rate.
Rudolph et al. [52] used spatial spectroscopy to identify 15
cephalometric landmarks on 14 images and found no
statistical difference between manual and automatic
methods. Chen et al. [53] used neural networks and genetic
algorithms to find sub-images containing required
landmarks. These three methods rely on the generation of
a model of the gray levels around each point from a training
set and subsequent matching of this model to a new image to
identify relevant points. This approach is limited by its
dependence on the reproducibility of the image appearance
around each landmark across all images [49].
The application of pattern matching only, in the absence
of knowledge-based enhancements, can give rise to false
detections far from the expected landmark location,
reducing system accuracy [50].
The respective limitations of knowledge based and
learning methods have led to combined approaches. Sanei
et al. [54] overcame the dependence on image quality and
local image appearance by using rule based fuzzy logic
based on known anatomical relationships and reported high
accuracy for landmark location on cephalograms of both
adults and children. Hutton et al. [49] evaluated the use of
active shape models for cephalometric landmark location
and concluded that their method was not sufficiently
accurate for fully automated landmarking, but could be
used to provide initial landmark estimates. Grau et al. [50]
used knowledge-based edge detection to locate search areas
for landmarks, followed by template matching based on
mathematical morphology [51], for exact location of
landmarks. The accuracy of the combined method exceeded
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
landmarks. The combined method might be suitable for
routine clinical use if it included a landmark editing function
[50]. Ciesielski et al. [42] used knowledge of facial
geometry to determine search areas for four facial
landmarks followed by genetic programming to evolve a
program to find each landmark in its search region.
They found detection rates ranging from 63.9% (with
30.6% false alarm rate) to 100% (with 0% false alarm rate).
3.1. X-ray stereo photogrammetry
2D radiographs are characterized by distortion and
magnification due to the fanbeam geometry of the X-ray
beam. These have to be corrected before quantitative
analysis of the shapes captured in images is possible. Stereo
photogrammetry not only allows 3D reconstruction of
cephalometric landmarks from radiographs, but also
corrects distortion and magnification, resulting in 3D
coordinates that can be displayed graphically or used in a
variety of measurements.
Locating the spatial coordinates of points in stereo X-ray
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
through stereoscopes for visual 3D point localization [55],
and might have originated with the successful location of a
metal object in the head [56,57]. The principles of X-ray
stereo photogrammetry are well known and are used in a
variety of medical applications [58]. Broadbent [59]
introduced 3D reconstruction of craniofacial landmarks
from stereo X-ray projections using orthogonal X-ray
sources. While the requirement for two X-ray sources and
the difficulty of locating homologous points in both images
have impeded implementation [57,60], refinements of the
Broadbent [59] method have been described [61]. The use of
a single X-ray source to obtain stereo images for
cephalometry in a digital X-ray imaging system has been
proposed [58].
4. Discussion
In addition to cephalograms and photographs, X-ray
computed tomography (CT) and magnetic resonance
imaging (MRI) have been used to obtain facial
morphology in three dimensions, and have the advantage
that both the surface and the underlying hard tissue can
be captured [9,23,62]. They provide 3D visualization of
the skull without any additional computational effort.
However, these methods are relatively expensive and
require co-operation from subjects during long scanning
periods. In addition, CT exposes the subject to higher
levels of ionizing radiation than does the acquisition of
planar X-ray images. Conventional X-rays have therefore
remained the standard for cephalometric imaging,
although multiplanar reconstruction computed tomogra-
phy (MPR-CT) is now used widely for preoperative
mandibular examinations [63]. To date, image processing
and 3D landmark reconstruction from cephalograms have
been applied mostly to digitized radiographs. Direct
digital imaging would provide images that are more
easily manipulated, yielding more reliable results.
Douglas et al. [58] have investigated 3D point localiza-
tion in low dose digital X-ray images, and found
accuracies consistent with those reported by others for
cephalometric studies.
X-ray cephalometry does not provide the natural
appearance of the facial surface. The suitability of surface
anthropometry for soft tissue landmarks and cephalometry
for bony landmarks suggests that both modalities should be
used for the planning of surgery in which the bony facial
structure is modified in order to alter surface appearance.
Ayoub et al. [23] achieved co-registration of cephalograms
with 3D surface data obtained from photogrammetry
for simultaneous viewing of soft tissue and bone for
maxillofacial surgical planning. Such fusion of data
from different medical image sources is an active
research area [64] and holds promise for the enhancement
of surgical planning.
An interactive and a fully automatic image processing
algorithm have been presented for the extraction of surface
facial landmarks used in syndrome diagnosis from 2D
images [34,35]. The rejection of unsuitable images by the
automatic method and the underestimation of the
endocanthion in some images might be avoided with
the introduction of user interaction, yielding better accuracy
on a larger number of input images. The effect of infrared
lighting during image acquisition on the clarity of facial
features and hence the accuracy of feature extraction is
worth investigating. Feature extraction directly from 3D
facial models eliminates measurement errors associated
with the selection of corresponding points that are not truly
homologous on stereo images. However, the construction of
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
landmark data rather than more sophisticated information
such as volume or surface curvature, 3D landmark
coordinate construction might be more appropriate than
3D models.
Once landmarks have been identified, further
investigation is possible with the aid of several shape
analysis methods which have to date been applied primarily
to manually extracted landmarks, but which may be applied
to automatically or semi-automatically extracted landmarks.
Procrustes methods, thin plate spline analysis and active
shape models have already been used on landmark data after
image processing. In addition, pattern profile analysis,
Euclidean distance matrix analysis, finite element modeling
and medial axis transformation belong to the set of shape
analysis tools available for landmark data [40].
While landmarks are more difficult to locate manually in
cephalograms than in photographs, more image processing
efforts have been aimed at cephalograms than at
photographs, exploiting the presence of structurally mean-
ingful lines and edges and the absence of superficial
variations in appearance caused by hair and skin color in
cephalograms. The variations caused by the skeletal
deformities often analyzed on cephalograms would,
however, render fully automatic landmark extraction
difficult. Computer assisted methods have been used with
manual landmark location to calculate 3D coordinates in
cephalograms [57,60]. 3D methods in cephalometry have
thus been limited to the reconstruction of landmarks from a
small number of images and successful image processing
for improved landmark extraction on 2D cephalograms
would lead to more efficient 3D methods.
Given the individual variations in craniofacial shape and
the high accuracies required for anthropometric data,
maintaining a degree of user interaction in landmark
identification algorithms, both for surface anthropometry
and cephalometry, might serve the purpose of
simplifying the clinicians task while ensuring that accuracy
requirements are met. Fuzzy landmarks, obtained manually
from CT images and an electromagnetic digitizer, have been
 T.S. Douglas / Computerized Medical Imaging and Graphics 28 (2004) 401409
used to overcome difficulties in locating biological
structures occupying a larger area than a single point in
order to obtain information on the cranial surface [65];
image processing algorithms are well suited to and might be
used for such fuzzy delineation.
Determining the accuracy of a feature extraction or
segmentation method is difficult in medical imaging, where
no gold standard of measurement exists for the complex
structures being examined. New measurement methods for
surface anthropometry are validated by comparison with
direct measurements and their accuracy described in
terms of their agreement with direct measurements.
Direct measurement using a ruler or calipers is subject to
errors of parallax, inter-operator variability and instrument-
dependent variability. Image processing methods can also
be validated by comparing their results with those of manual
measurement on images displayed on a computer screen.
In cephalometry, direct measurement is only possible on dry
skulls, and validation of image processing algorithms
relies on comparison with manual measurements from
displayed images.
A difference of less than 1 mm between a new method
and direct measurement in surface anthropometry is
generally regarded as acceptable in published work [66].
The literature varies on the accuracy acceptable for
cephalometric landmarks: Rakosi [67] has suggested that
an error of 2 mm is acceptable, while Forsyth [68] and
Richardson [69] have indicated that 1 mm is desirable.
Although an error of 1 mm could result in a
misclassification of a borderline case, such misclassification
could be minimized by the use of fuzzy diagnostic borders
and the use of a combination of features for diagnosis.
Comparison of the performance of image processing
algorithms in terms of their accuracy in identifying a
particular landmark or measuring a particular feature is
problematic when the algorithms are applied to images
obtained using different image acquisition protocols that
produce images of varying quality. In addition, the standard
with which the results of image processing are compared
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].
Normative data for surface anthropometry have primarily
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
surface anthropometry may be translated to the choice of
imaging system and image processing algorithm for
craniofacial landmark measurement based on photographs
and cephalograms.
407
5. Summary
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 and examine the geometric
variation in the relative location or pattern of these
landmarks in different individuals. Image processing
algorithms applied to facial images have the potential to
enhance anthropometric applications through reductions in
the time spent on examinations and improvements in the
reliability of measurements, enabling automatic
measurement of clinically relevant distances and angles,
as well as shape analysis and comparison. Stereo
photogrammetry has been used to obtain 3D coordinates
of landmarks both from stereo photographs and stereo
radiographs (cephalograms). Thanks to advances in imaging
technology, surface anthropometry has been extended to the
analysis of full 3D models of faces, although not routinely.
The volumetric 3D extension of X-ray imaging, namely CT,
is well established, but its cost and high dose of ionizing
radiation have prevented its routine clinical use for
cephalometry. Much research is therefore in progress to
optimize the extraction of useful cephalometric information
from planar X-ray images. This paper reviews facial surface
anthropometry and cephalometry with reference to the
image processing algorithms that have been applied and
their effectiveness. Despite achievements in 3D reconstruc-
tion of landmarks in surface anthropometry and cephalo-
metry, 3D modeling of complete faces, and the application
of sophisticated image processing algorithms, fully auto-
mated anthropometric systems have not been reported.
Individual variation in shape and distortions of the normal
shape represented by malformations render automation
difficult, as in all areas of medical imaging. Also, and again
in common with other medical imaging applications, the
accuracy of image processing techniques in landmark
extraction and measurement is hard to quantify.
Acknowledgements
This paper was written with the aid of a grant from
the National Research Foundation in South Africa
(GUN2053094).
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Tania Douglas is a senior lecturer in the Department of Human Biology
at the University of Cape Town. She holds a BSc in Electrical and
Electronic Engineering from the University of Cape Town, an MS in
Biomedical Engineering from Vanderbilt University and a PhD in
Bioengineering from the University of Strathclyde, and completed a
postdoctoral fellowship at the Japan Broadcasting Corporation in Tokyo.
Her current research projects include facial feature extraction for fetal
alcohol syndrome screening, 3D point localization in low-dose X-ray
images and image analysis to detect tuberculosis in sputum smears.