{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T00:21:25Z","timestamp":1793319685790,"version":"4.5.0"},"reference-count":27,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T00:00:00Z","timestamp":1773273600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Dentistry Journal"],"abstract":"<jats:p>Objectives: This study evaluated the accuracy of an artificial intelligence (AI)-based cephalometric software (WebCeph version 2.0.0.) compared with manual tracing and determined whether stratifying patients by chronological age or dentition stage provides a more clinically relevant assessment of AI accuracy. Methods: Three hundred lateral cephalometric radiographs of Vietnamese patients were traced manually by an orthodontist (reference standard) and analyzed automatically by WebCeph. Intra-observer reliability was validated using ICC and Dahlberg\u2019s error. We analyzed the data using three stratification strategies: (1) Overall; (2) Chronological age (&lt;18, 18\u201325, &gt;25 years); and (3) Dentition stage (&lt;9 primary-early mixed, 9\u201312 late mixed, &gt;12 permanent). The primary outcome was the absolute measurement difference (\u2223\u0394\u2223), analyzed using the Kruskal\u2013Wallis test and effect size (\u03b72). Results: Overall, WebCeph showed high concordance with manual tracing (ICC &gt; 0.80 for most parameters). Chronological age stratification showed weak associations with measurement error; differences between groups were largely non-significant (p&gt;0.05) with a small effect size (\u03b72\u22480.015). In contrast, the dentition stage revealed significant performance disparities (p&lt;0.05). Notably, accuracy for the Mandibular Arc (ICC = 0.349) and Mandibular Plane Angle (p=0.048) degraded significantly in the primary-early mixed group, a vulnerability obscured by chronological age-based stratification. Conclusions: Dentition stage is a more sensitive and biologically relevant predictor of AI accuracy than chronological age. While WebCeph is reliable for permanent dentition, accuracy degrades significantly in the primary-early mixed phase. Clinicians should prioritize manual verification of mandibular and incisor landmarks in mixed-dentition children.<\/jats:p>","DOI":"10.3390\/dj14030167","type":"journal-article","created":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T13:12:24Z","timestamp":1773321144000},"page":"167","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Reliability of Automated Cephalometric Analysis: A Comparative Assessment of Stratification Strategies Based on Chronological Age Versus Dentition Stage"],"prefix":"10.3390","volume":"14","author":[{"given":"Anh Thi Ngoc","family":"Do","sequence":"first","affiliation":[{"name":"Faculty of Dentistry, University of Medicine and Pharmacy at HCM City, Ho Chi Minh City 700000, Vietnam"},{"name":"Faculty of Dentistry, Nguyen Tat Thanh University, Ho Chi Minh City 700000, Vietnam"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-1624-2386","authenticated-orcid":false,"given":"Hung Trong","family":"Hoang","sequence":"additional","affiliation":[{"name":"Faculty of Dentistry, University of Medicine and Pharmacy at HCM City, Ho Chi Minh City 700000, Vietnam"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1133-1433","authenticated-orcid":false,"given":"Hieu Ngoc","family":"Le","sequence":"additional","affiliation":[{"name":"Faculty of Information Technology, Van Hien University, Ho Chi Minh City 700000, Vietnam"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5941-4900","authenticated-orcid":false,"given":"Thuy-Trang Thi","family":"Ho","sequence":"additional","affiliation":[{"name":"Faculty of Dentistry, University of Medicine and Pharmacy at HCM City, Ho Chi Minh City 700000, Vietnam"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"84","DOI":"10.5005\/jp-journals-10021-1014","article-title":"A Comparative Study of Cephalometric Measurements with Digital versus Manual Methods","volume":"45","author":"Agarwal","year":"2011","journal-title":"J. Indian Orthod. Soc."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1111\/ocr.12542","article-title":"Assessment of automatic cephalometric landmark identification using artificial intelligence","volume":"24","author":"Bulatova","year":"2021","journal-title":"Orthod. Craniofac. Res."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"309","DOI":"10.31393\/reports-vnmedical-2024-28(2)-22","article-title":"Ricketts cephalometric method in orthodontic diagnosis","volume":"28","author":"Brotskyi","year":"2024","journal-title":"Rep. Vinnytsia Natl. Med. Univ."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1016\/0002-9416(83)90322-6","article-title":"The analysis of errors in orthodontic measurements","volume":"83","author":"Houston","year":"1983","journal-title":"Am. J. Orthod."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"727","DOI":"10.5005\/jp-journals-10015-2285","article-title":"Accuracy and Reliability of WebCeph Digital Cephalometric Analysis in Comparison with Conventional Cephalometric Analysis","volume":"14","author":"Azeez","year":"2023","journal-title":"World J. Dent."},{"key":"ref_6","first-page":"501","article-title":"Enhanced speed and precision of measurement in a computer-assisted digital cephalometric analysis system","volume":"74","author":"Chen","year":"2004","journal-title":"Angle Orthod."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"105513","DOI":"10.1016\/j.cmpb.2020.105513","article-title":"Web-based fully automated cephalometric analysis by deep learning","volume":"194","author":"Kim","year":"2020","journal-title":"Comput. Methods Programs Biomed."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1158","DOI":"10.1007\/s10278-022-00766-w","article-title":"Artificial Intelligence for Detecting Cephalometric Landmarks: A Systematic Review and Meta-analysis","volume":"36","author":"Mesquita","year":"2023","journal-title":"J. Digit. Imaging"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"20190107","DOI":"10.1259\/dmfr.20190107","article-title":"The use and performance of artificial intelligence applications in dental and maxillofacial radiology: A systematic review","volume":"49","author":"Hung","year":"2020","journal-title":"Dentomaxillofac. Radiol."},{"key":"ref_10","first-page":"e40934","article-title":"Artificial Intelligence and Machine Learning for Automated Cephalometric Landmark Identification: A Meta-Analysis Previewed by a Systematic Review","volume":"15","author":"Rauniyar","year":"2023","journal-title":"Cureus"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Polizzi, A., Nucci, L., Serra, S., Isola, G., and Leonardi, R. (Semin. Orthod., 2025). Accuracy of artificial intelligence fully-automatic cephalometric analysis in linear and angular measurement: A critical scoping review, Semin. Orthod., in press.","DOI":"10.1053\/j.sodo.2025.08.008"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1177\/03015742231214376","article-title":"A Comparison of Smartphone-assisted and Computer Software Assisted Tracing with the Conventional Manual Method","volume":"58","author":"Kastury","year":"2024","journal-title":"J. Indian Orthod. Soc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1093\/ejo\/cjr008","article-title":"Reliability of four different computerized cephalometric analysis programs","volume":"34","author":"Erkan","year":"2012","journal-title":"Eur. J. Orthod."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"3205","DOI":"10.1002\/sim.935","article-title":"Planning a reproducibility study: How many subjects and how many replicates per subject for an expected width of the 95 per cent confidence interval of the intraclass correlation coefficient","volume":"20","author":"Giraudeau","year":"2001","journal-title":"Stat. Med."},{"key":"ref_15","unstructured":"Kharbanda, O. (2013). Orthodontics: Diagnosis and Management of Malocclusion and Dentofacial Deformities, Elsevier. [2nd ed.]."},{"key":"ref_16","first-page":"1","article-title":"Normal and abnormal growth of the mandible. A synthesis of longitudinal cephalometric implant studies over a period of 25 years","volume":"5","author":"Skieller","year":"1983","journal-title":"Eur. J. Orthod."},{"key":"ref_17","first-page":"123","article-title":"Comparative study between manual and digital cephalometric tracing using Dolphin Imaging software with lateral radiographs","volume":"15","author":"Sobral","year":"2010","journal-title":"Dent. Press J. Orthod."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","article-title":"A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research","volume":"15","author":"Koo","year":"2016","journal-title":"J. Chiropr. Med."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Mahto, R.K., Kafle, D., Giri, A., Luintel, S., and Karki, A. (2022). Evaluation of fully automated cephalometric measurements obtained from web-based artificial intelligence driven platform. BMC Oral Health, 22.","DOI":"10.1186\/s12903-022-02170-w"},{"key":"ref_20","unstructured":"Proffit, W.R., Fields, H.W., Larson, B., and Sarver, D.M. (2018). Contemporary Orthodontics, Elsevier. [6th ed.]."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e2524157","DOI":"10.1590\/2177-6709.30.3.e2524157.oar","article-title":"Evaluation of reliability and reproducibility of artificial intelligence-based, computer-based and traditional manual tracing methods","volume":"30","author":"Arslan","year":"2025","journal-title":"Dent. Press J. Orthod."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Zughair, S.A.K., Ishaq, R.A.R., Al-dossary, O.A.I., Aldhorae, K., Saber, N.H., and Elayah, S.A. (2025). Evaluation of artificial intelligence-based cephalometric tracing versus semi-automatic and manual tracing. BMC Oral Health, 25.","DOI":"10.1186\/s12903-025-06765-x"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1016\/j.ajodo.2025.04.011","article-title":"Accuracy and reliability of 2 artificial intelligence platforms for cephalometric analysis compared with a semiautomatic computer program","volume":"168","author":"Raby","year":"2025","journal-title":"Am. J. Orthod. Dentofac. Orthoped."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1007\/s11547-023-01629-2","article-title":"Accuracy of automated 3D cephalometric landmarks by deep learning algorithms: Systematic review and meta-analysis","volume":"128","author":"Serafin","year":"2023","journal-title":"Radiol. Med."},{"key":"ref_25","unstructured":"Bishara, S.E. (2001). Textbook of Orthodontics, W.B. Saunders Company."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1067\/mod.2002.129191","article-title":"Landmark identification on direct digital versus film-based cephalometric radiographs: A human skull study","volume":"122","author":"Schulze","year":"2002","journal-title":"Am. J. Orthod. Dentofac. Orthoped."},{"key":"ref_27","first-page":"57","article-title":"The accuracy and reliability of WebCeph for cephalometric analysis","volume":"17","author":"Yassir","year":"2022","journal-title":"J. Taibah Univ. Med. Sci."}],"container-title":["Dentistry Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/3\/167\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T14:19:10Z","timestamp":1773325150000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/3\/167"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,12]]},"references-count":27,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["dj14030167"],"URL":"https:\/\/doi.org\/10.3390\/dj14030167","relation":{},"ISSN":["2304-6767"],"issn-type":[{"value":"2304-6767","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,12]]}}}