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Table of Contents   
ORIGINAL RESEARCH  
Year : 2016  |  Volume : 27  |  Issue : 4  |  Page : 370-377
The reliability of cephalometric measurements in oral and maxillofacial imaging: Cone beam computed tomography versus two-dimensional digital cephalograms


1 Department of Oral Medicine and Radiology, Bangalore Institute of Dental Sciences, Post Graduate Research Centre, Bengaluru, Karnataka, India
2 Department of Oral Medicine and Radiology, KGF Institute of Dental Sciences, Kolar, Karnataka, India

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Date of Submission18-Nov-2015
Date of Decision29-Feb-2016
Date of Acceptance29-Jul-2016
Date of Web Publication10-Oct-2016
 

   Abstract 

Context: This study compared digital two-dimensional (2D) lateral cephalograms and cone-beam computed tomography (CBCT) total and half-skull images for the reliability of cephalometric measurements.
Aims: (1) To compare the accuracy of cephalometric measurements and reproducibility between the digital and CBCT cephalograms in the Indian population. (2) To compare interobserver variability in landmark identification through their cephalometric measurements by comparing different imaging modalities (CBCT total skull, CBCT half-skull, and conventional lateral cephalogram). (3) To further compare half-skull with the total skull synthesized CBCT and digital cephalograms in the same regard.
Materials and Methods: Thirty patients, who had consented with orthodontic treatment, participated in the study. Informed consent was obtained from the patient before the radiographic procedures. 2D digital lateral cephalograms and their corresponding CBCT scans were taken and imported in DICOM format to OnDemand 3D software. Twenty-three landmarks were identified by 3 observers and 9 linear and 14 angular measurements were digitally traced. The values were sent for statistical analysis using ANOVA to check the interobserver reliability between the imaging modalities.
Statistical Analysis Used: ANOVA, Student's t-test, and post hoc test were used for the statistical analysis.
Results: The interobserver reliability was high between the modalities. CBCT total skull received an overall intraclass correlation coefficient (ICC) value of 0.76. The ICC value for the CBCT half-skull was 0.79 and for the digital cephalograms it was 0.80. The reliability for CBCT total skull was marginally less when compared to the CBCT half-skull and digital cephalograms, but more for the mid-sagittal measurements. Digital cephalograms showed the most variation with measurements of the mandibular plane when compared to CBCT.
Conclusions: CBCT has the potential to be used for cephalometrics, especially the half-skull images, but further studies are required to prove whether CBCT total skull images can be used. 2D cephalometry, however, still does remain as the mainstay of orthodontic diagnosis and treatment planning and cannot be easily replaced by three-dimensional cephalometry.

Keywords: Cone beam computed tomography half-skull, computed tomography, cone beam computed tomography, digital cephalometry

How to cite this article:
Hariharan A, Diwakar N R, Jayanthi K, Hema H M, Deepukrishna S, Ghaste SR. The reliability of cephalometric measurements in oral and maxillofacial imaging: Cone beam computed tomography versus two-dimensional digital cephalograms. Indian J Dent Res 2016;27:370-7

How to cite this URL:
Hariharan A, Diwakar N R, Jayanthi K, Hema H M, Deepukrishna S, Ghaste SR. The reliability of cephalometric measurements in oral and maxillofacial imaging: Cone beam computed tomography versus two-dimensional digital cephalograms. Indian J Dent Res [serial online] 2016 [cited 2020 Oct 21];27:370-7. Available from: https://www.ijdr.in/text.asp?2016/27/4/370/191884
"Diagnosis is not the end, but the beginning of practice." A good diagnosis is always instrumental for proper treatment planning.[1] Cephalometric radiography is a standardized method of production of skull radiographs, which are useful in making measurements of the cranium and the orofacial complex.[2] It is an essential tool for orthodontic practice and research, which provides elaborate information for diagnosis and treatment planning.[2]

Digital cephalometry was introduced in the late 1960s using the same principles which aided in reducing the time consumption for image acquisition.[3] Recently, cone-beam computed tomography (CBCT) became the preferred method instead of CT due to the reduction in the radiation dosage for the patient.[4] It has proved its value in dental practice when conducting craniofacial measurements.[5]

The aim of this study is to compare the interobserver reliability and precision of cephalometric landmark identification and measurements using CBCT and digital two-dimensional (2D) lateral cephalograms and to evaluate if CBCT is a more accurate choice in orthodontic diagnosis and treatment planning. A recently introduced half-skull CBCT cephalogram will also be evaluated and compared with total-skull CBCT and digital lateral cephalograms. Measurements and landmark identification for both the cephalograms will be done digitally using a computer-aided software for analysis.


   Materials and Methods Top


The study was carried out on thirty patients visiting the Department of Orthodontics at Bangalore Institute of Dental Sciences for Orthodontic treatment. Informed consent for the study to be carried out was taken from the patients, and ethical clearance was obtained from the University Board. The procedure was explained to the patients in their own language. Patients with no gross asymmetry were included in the study. Patients who suffered any trauma to the maxillofacial region, or were medically compromised were excluded from this study.

The 2D digital lateral cephalograms for thirty patients were obtained at the institution using the Rotograph Evo D Machine (Villa Sistemi Medicali, Milan, Italy) (72 kV, 10 mA, 4.5 s). Following that, their corresponding CBCT scans were taken using KODAK 9500 CBCT Machine (Carestream Health Inc, Rochester, New York, USA) (90 kV, 10 mA, 10.8 s). All the images were then saved in DICOM format and imported into the OnDemand 3D software (Cybermed Inc., Korea) for analysis.

For the image acquisition of the 2D digital images and the CBCT images,[5] standard guidelines for the patient positioning were employed [Figure 1]. In the software, two techniques were used for controlling the anteroposterior head rotation for the CBCT. The Frankfort horizontal plane was adjusted so that it was completely horizontal in the sagittal view. In the axial view, the mid-sagittal plane was oriented vertically and in the coronal view, the transporionic line was oriented horizontally[5] [Figure 2]. The right-side half-skull images were generated by segmenting a section of the total three-dimensional (3D) reconstructed volumetric image and eliminating the unwanted left side. The thickness of the generated image was reduced by half[4] [Figure 3].
Figure 1: Acquired image in the digital lateral cephalogram

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Figure 2: Orientation for the cone beam computed tomography total skull images was done by using intra-cranial reference planes

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Figure 3: Cone beam computed tomography half-skull images were synthesized by using the segmentation tool in the software to remove the unwanted side of the skull. The image thickness was also reduced by half

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Cephalometric analysis was performed on both the digital and CBCT-synthesized cephalograms (total and half-skull images) using the same software. Three observers (a postgraduate student, a senior lecturer, and an assistant professor) from the Department of Orthodontics, Bangalore Institute of Dental Sciences, Bengaluru, were selected to plot the landmarks at different times. The observers were trained on the usage of the software, and a list of standard definitions of the chosen landmarks was given to each of them for their reference[6],[7] [Table 1]. Facilities of changing the sharpness, contrast, and the brightness for better viewing of the images were available in the software for each observer as per their requirements. While doing the analyses for the digital cephalograms, a magnification factor of 1.1 mm was subtracted from each measurement as per the manufacturer settings of the Rotograph Evo D machine. The axial slice thickness used was standard at 0.4 mm with isotropic voxels for the CBCT images.[7] The software had the option of doing 2D and 3D measurements, so for the CBCT total skull, 3D measurements were calculated directly on the 3D volumetric image. For the half-skull CBCT and digital cephalograms, they were synthesized into 2D DICOM images, and 2D measurements were obtained on them. A total of 23 landmarks were plotted for thirty patients. Fourteen angular and 9 linear measurements were done for each imaging modality per patient [Table 2]. The obtained values were then transferred to an Excel Master Chart (Microsoft Excel 2007) for statistical analysis using SPSS software 18.0 for the analysis of the interobserver variability and the comparison with the measurements obtained of the skull. The ANOVA test was done to evaluate the interobserver variability and accuracy of landmark identification and their measurements for each imaging modality. The intraclass coefficient was used to analyze the agreement of the measurements between the three observers.
Table 1: Definitions of the Chosen Cephalometric Landmarks


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Table 2: The Chosen Linear and Angular Measurements


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   Results Top


Twenty-three landmarks were identified by 3 observers and 9 linear and 14 angular measurements were plotted [Figure 4]a-c and [Figure 5]-c, [Table 3] and [Table 4]. The interobserver reliability for each measurement under each modality was calculated using one-way ANOVA test. The mean and the standard deviations were calculated for each measurement under CBCT and digital cephalograms.
Figure 4: (a) Example of a patient's linear measurements plotted by an observer on the cone beam computed tomography total skull image. (b) Example of a patient's linear measurements plotted by an observer on the cone beam computed tomography half-skull image. (c) Example of a patient's linear measurements plotted by an observer on the digital lateral ceph image

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Figure 5: (a) Example of a patient's angular measurement (ArGoMe) plotted by an observer on a cone beam computed tomography total skull image. (b) Example of a patients angular measurement (ArGoMe) plotted by an observer on a cone beam computed tomography half-skull image. (c) Example of a patient's angular measurement (ArGoMe) plotted by an observer on a digital lateral ceph image

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Table 3: Example of the Recorded Linear Measurements of a Patient


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Table 4: Example of Recorded Angular Measurements of a Patient


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The standard deviation of error was generally high for the CBCT total skull when compared to the CBCT half-skull and digital cephalogram for six of the linear measurements and four of the angular measurements. The linear measurements of ANS-Me, N-ANS, and S-N showed the least standard deviation in CBCT total skull. For these measurements, the digital modality had the highest standard deviation. The angular measurements involving the Ar landmark (SNAr, SArGo, and ArGoMe) showed the highest standard deviation, more so in the CBCT total skull. BaSN also showed a high standard deviation. The angles involving the mid-sagittal plane, showed less standard deviation in the CBCT when compared to the digital cephalograms. CBCT half-skull standard deviations were consistently low for all the measurements. From this, we can infer that for the mid-sagittal measurements involving the N landmark, CBCT proved to be a more precise modality, whereas, for the lateral measurements, the digital cephalograms were more precise.

The overall significance level was assessed based on variation in the measurements between the three tested modalities and also the interobserver variation in the measurements within each modality. There was a high level of significance between groups as well as within each group for both linear and angular measurements. The only nonsignificant linear measurements were N-Me and ANS-Me, which showed once again that there was a good agreement between the observers as well as the modalities for the mid-sagittal landmarks and measurements. Five angular measurements did not show any level of significance between the observers (FMA, IMPA, NAPog, ABN, and SNA).

Post hoc tests were further done to assess which modality displayed the highest variations in the measurements [Table 5] and [Table 6]. The measurements with no significant variation were omitted from this test. There was a high level of significance for the measurements involving the CBCT total skull modality. The comparison between CBCT total skull with the half-skull as well as with the digital cephalogram revealed a high level of significance. The only less significant linear measurement involving the total skull and half-skull was N-ANS, another measurement involving the mid-sagittal plane. The P value for this measurement was 0.040, which is almost nonsignificant. However, the same measurement showed a high level of significance when compared with the digital. The angular measurement ArGoN showed a high level of agreement between CBCT total skull and digital cephalogram, with a P value of 0.100, but high variation when compared to the CBCT half-skull image. Comparison of the linear and angular measurements between the CBCT half-skull and the digital cephalogram was nonsignificant, showing a high level of reliability. Only three angular measurements showed a high level of significance between CBCT half-skull and digital cephalograms (U1SN, U1NA, and MeGoN).
Table 5: Post Hoc Tests for the Linear Measurements Showing the Agreement Between Each Modality


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Table 6: Post Hoc Tests for the Angular Measurements Showing the Agreement between Each Modality


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The intra-class correlation coefficient (ICC) showed the level of reliability between each modality [Table 7], [Table 8], [Table 9]. All three modalities had a substantially high interobserver reliability for each measurement. The CBCT total skull had a higher reliability with the mid-sagittal linear measurements. The conventional cephalograms had a more consistent and marginally higher ICC values overall when compared to the CBCT total skull. The CBCT half-skull also had a high interobserver reliability, and the overall ICC values were in agreement with the digital cephalograms. The lowest ICC value obtained was 0.69 for the IMPA angle, by the digital cephalograms. Incidentally, the CBCT total skull volumes recorded the highest ICC value of 0.89 for the measurement, S-N.
Table 7: Inter-observer Reliability for Linear Measurements


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Table 8: Inter - observer Reliability for Angular Measurements


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Table 9: Overall Inter - observer Reliabilities for each Modality


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   Discussion Top


This study focused on the comparison between digital lateral cephalometry and CBCT in the variability and reproducibility of cephalometric measurements. CBCT is increasingly becoming the investigative modality of choice when it comes to diagnosis and treatment planning, but as obtained in this study, there are variations in which type of CBCT image will provide accurate measurements.

The CBCT total skull image showed a high standard deviation of error for some of the linear and the angular measurements but was generally comparable to that of 2D lateral cephalograms. For example, linear measurements such as ANS-Me, N-ANS, and S-N displayed the least standard deviation, whereas the highest standard deviation came from the measurements involving Ar, i.e., S-Ar, Ar-Go, and S-Go. The standard deviation for the angular measurements involving the mid-sagittal plane and the dental structures, i.e. U1NA, U1SN, and ABN was found to be consistently <3°. This correlates with the study by Farhadian et al.,[8] which also showed that there was a high standard deviation for the Ar-Go measurement. However, in their study, the U1SN measurement revealed a much higher standard deviation than our study. The highest standard deviations were seen in the measurements involving the Ar landmark, such as ArGoMe, SArGo, and SNAr, which were consistently high. Even though the measurements involving the ramus height do appear to have a higher standard of deviation, CBCT seems to be a good alternative as a gold standard.[8]

The CBCT half-skull also showed a high standard deviation for selected measurements but was consistently low when compared to the CBCT total skull. For the linear measurements, the highest standard deviation was seen in the measurements Co-Gn, Ar-Go, and S-Go. The highest standard deviations for the angular measurements were present for the SArGo and BaSN angular measurements. This implies that the CBCT half-skull produces consistent angular measurements, which could lead to a good interobserver reliability. This is in accordance to the study by Liedke et al.[4] because the outcome of his study also revealed that CBCT half-skull produced consistent angular and linear measurements. Their study states that the reproducibility of measurements is a crucial factor in cephalometric analyses.[4] CBCT-synthesized half-skull images appear to be competent in cephalometric analyses. They allow for the representation of the right and left sides of the skull separately and therefore the accurate positioning of the landmarks is further enhanced.[4] The question of superimposition is out of the equation in this case and has been proven in this study.

The digital lateral cephalograms displayed a relatively high standard deviation also. The standard deviation was higher than the CBCT total and half-skull for four out of the nine linear measurements, namely, S-Go, N-ANS, N-Me, and Co-Gn, all involving the mandibular and mid-sagittal planes. This corresponds to the study by Navarro et al.,[9] who stated that the measurements involving the mandibular plane had the greatest standard deviation in the digital lateral cephalograms. The angular measurements were also less consistent when compared to the CBCT half-skull. It was found that the standard deviation was high in the measurements involving the mandibular plane, which was in accordance with the study by Farhadian et al.[8] They also got high standard deviations for mandibular plane angles. However, the results of our study were contrary to the study by Oz et al.[10] where they found that the standard deviation was <2° for all their tested measurements.

The majority of linear measurements had P < 0.05 when CBCT total skull was compared to the CBCT half-skull and digital cephalograms, which suggested a high level of significance. The reason attributed to this could be because 3D measurements involve taking the bony structures into account, leading to the discrepancy of the measurements.[9] The study by Kumar[11] suggested that the variability was less between the modalities for the mid-sagittal measurements, like N-ANS, which corresponds to the results obtained in this study.

The interobserver reliability between the measurements revealed that the ICC values were substantially reliable [Table 7], [Table 8], [Table 9]. All three modalities showed an overall reliability in the range of 0.76-0.80. The digital cephalograms showed the highest reliability of 0.80, whereas the CBCT total skull showed the least reliability of 0.76. The CBCT half-skull showed a high level of reliability of 0.79, which is in agreement with the digital cephalograms and therefore suggests it to be a highly reliable modality. This was in accordance to the study by Liedke et al.,[4] who also found a high level of agreement between CBCT half-skull and conventional cephalograms. The values in this study were comparatively lower than the previous study by Kim et al.,[12] where all the ICC values were consistently above 0.9 for all the linear measurements in both modalities.

CBCT total skull measurements proved to be the least reliable, particularly because of the inconsistencies noted with 3D measurements. Furthermore, the experience level of the observers in this study would have made a difference. The reason for the low ICC values in our study could be attributed to the fact that the three observers were at three different levels of experience in orthodontics, ranging from a postgraduate student to an assistant professor. However, the results showed that there is less ambiguity when using the CBCT half-skull images when compared to the CBCT total skull images. The digital lateral cephalograms had the highest reliability, which suggests that it is still more competent in appearing as the gold standard for cephalometric measurements. Another study by da Silva et al.[2] showed that the angular measurements SNA, SNB, FMA, IMPA, and ABN were consistently above 0.95. In this study, the values were lower at the 0.7-0.8 region.

Final comparisons indicated that the interobserver reliability was found to be substantially high for all the modalities. There was a high reliability between the CBCT half-skull and the digital cephalogram modalities. It was found that the measurements involving the mid-sagittal plane were more accurate in CBCT when compared to the digital cephalograms. This correlates with the study by Gribel et al.,[13] who found that the mid-sagittal measurements had a greater variation in the digital cephalograms, and they attributed this to the magnification. This is an important finding because it has always been difficult to locate mid-sagittal landmarks.[14] The mid-sagittal plane is significant for orthodontic treatment planning because it gives the extent of the dental asymmetry. A study by Ruellas et al.[14] stated that CBCT is a valid tool for evaluating the dental asymmetry in relation to the skeletal midline. In their study, all the dental-related landmarks were found to be reproducible.


   Conclusion Top


Therefore, based on the results obtained, we found that the 2D images generated by CBCT, like the half-skull, were competent in performing cephalometric analysis, but further studies are required to determine the efficacy of CBCT total skull for the same. It was also established that digital cephalometry still remains to be a mainstay in orthodontics and cannot be completely replaced by 3D cephalometry. Further studies are also required to obtain an imaging modality that can act as a gold standard for cephalometric measurements, but for now, 2D digital lateral cephalometry is here to stay as the gold standard for cephalometric measurements. However, CBCT is a more than competent modality for performing cephalometric measurements, especially the CBCT half-skull images.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Thomas A. History of Radiology. Available from: http://www.bir.org.uk/patients-public/history-of-radiology/. [Last accessed on 2014 Aug 04].  Back to cited text no. 1
    
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da Silva MB, Gois BC, Sant′Anna EF. Evaluation of the reliability of measurements in cephalograms generated from cone beam computed tomography. Dental Press J Orthod 2013;18:53-60.  Back to cited text no. 2
    
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de Araújo Guedes P, Souza JÉ, Tuji FM. A comparative study of manual vs. computerized cephalometric analysis. Dent Press J Orthod 2010;15:44-51.  Back to cited text no. 3
    
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Liedke GS, Delamare EL, Vizzotto MB, da Silveira HL, Prietsch JR, Dutra V, et al. Comparative study between conventional and cone beam CT-synthesized half and total skull cephalograms. Dentomaxillofac Radiol 2012;41:136-40.  Back to cited text no. 4
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Ludlow JB, Gubler M, Cevidanes L, Mol A. Precision of cephalometric landmark identification: Cone-beam computed tomography vs conventional cephalometric views. Am J Orthod Dentofacial Orthop 2009;136:312.e1-10.  Back to cited text no. 5
    
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Bhalajhi SI. Orthodontics - Art and Science. 3 rd ed. Bengaluru, Karnataka, India: Arya (Medi) Publishing House; 2004. p. 143-61.  Back to cited text no. 6
    
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Swennen GR, Schutyser F, Hausamen JE. Three - Dimensional Cephalometry: A Color Atlas and Manual. Berlin, Germany: Springer Verlag Berlin Heidelberg; 2006. p. 116.  Back to cited text no. 7
    
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Farhadian N, Miresmaeili AF, Mahvelati R, Sajedi A. A comparative cephalometric analysis between conventional and CBCT generated lateral cephalograms. Iran J Orthod 2012;7:22-6.  Back to cited text no. 8
    
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Navarro Rde L, Oltramari-Navarro PV, Fernandes TM, Oliveira GF, Conti AC, Almeida MR, et al. Comparison of manual, digital and lateral CBCT cephalometric analyses. J Appl Oral Sci 2013;21:167-76.  Back to cited text no. 9
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Oz U, Orhan K, Abe N. Comparison of linear and angular measurements using two-dimensional conventional methods and three-dimensional cone beam CT images reconstructed from a volumetric rendering program in vivo. Dentomaxillofac Radiol 2011;40:492-500.  Back to cited text no. 10
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Kumar V, Ludlow J, Soares Cevidanes LH, Mol A. In vivo comparison of conventional and cone beam CT synthesized cephalograms. Angle Orthod 2008;78:873-9.  Back to cited text no. 11
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Kim M, Huh KH, Yi WJ, Heo MS, Lee SS, Choi SC. Evaluation of accuracy of 3D reconstruction images using multi-detector CT and cone-beam CT. Imaging Sci Dent 2012;42:25-33.  Back to cited text no. 12
    
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Gribel BF, Gribel MN, Frazäo DC, McNamara JA Jr., Manzi FR. Accuracy and reliability of craniometric measurements on lateral cephalometry and 3D measurements on CBCT scans. Angle Orthod 2011;81:26-35.  Back to cited text no. 13
    
14.
Ruellas AC, Koerich L, Baratieri C, Mattos CT, Alves M Jr., Brunetto D, et al. Reliability of CBCT in the diagnosis of dental asymmetry. Dental Press J Orthod 2014;19:90-5.  Back to cited text no. 14
    

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Correspondence Address:
Dr. Arvind Hariharan
Department of Oral Medicine and Radiology, Bangalore Institute of Dental Sciences, Post Graduate Research Centre, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.191884

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]

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