## 2 Materials and Methods  
This paper addresses the agreement between digital and manual technique used to evaluate the complexity of orthodontic treatment through a cross-sectional study that was carried out on 28 patients who were recruited from February 2021 to May 2022 and scheduled for orthodontic treatment at the Faculty of Denistry, at the Autonomous University of Mexico State. The patients were randomly chosen regardless of their malocclusion type or sex and gave their informed consent. The sample consisted of 28 initial orthodontic records in a digital format and 28 physical records for the same patients, and was equally evaluated. All protocols were approved by the bioethics committee of the Center for Research and Advanced Studies in Dentistry (CEICIEAO-2021-005). Digital records were obtained from a single dental office and included digital photographs, panoramic and lateral radiography of the skull, cone-beam tomography and intraoral scans obtained with iTero(r) (Align Technology, Tempe, AZ, USA) and TRIOS 3(3 Shape, Copenhagen, Denmark) and cephalometric tracing was performed in the Dolphin Imaging(r) program (Patterson Dental, Los Angeles, CA, USA). The physical records included printed photographs, printed panoramic and lateral skull radiographs, dental casts and manual cephalometric tracing. These records were secured to make an orthodontic diagnosis and thus obtaining the discrepancy index. Regarding the digital measurement, files corresponding to the intraoral scanning, cone-beam tomography, digital photographs, and radiographs were uploaded to the Ormco Digital(r) platform (Ormco, Brea, CA, USA). Subsequently, the company sent a treatment plan to be visualized with the Insignia(r) program (Ormco, Brea, CA, USA). The discrepancy index was obtained using the tools of the Digicast(r) section (Ormco, Brea, CA, USA) of the same program, and the 3D measurements were performed using this program (Figure 1). Cephalometric tracing was performed with the Dolphin Imaging(r) program, version 9.0 (Figure 2), and ABO tracing was predefined by the program based on the following cephalometric landmarks: ANB angle (A point-nasion-B point), SN-MP angle (sella-nasion-mandibular plane) and \(\overline{1}\) to MP (lower incisor to mandibular plane). Photographs, digital radiographs and cone-beam tomography were used to score the section \"other\".  
Manual measurements were performed with the ABO calibrated ruler, which is specially designed to determine the discrepancy index (Figure 3). Appropriately, cut study models were used and were placed on a flat surface and in maximum intercuspation for analysis. Concerning cephalometry, a lateral skull radiograph was used; the radiograph was traced on paper using a negatoscope to determine the ANB angle, SN-MP angle and \(\overline{1}\) to MP angle (Figure 4). Printed photographs and radiographs were used to score the \"other\" section.  
Figure 1: **(A,B) Digital overjet and overbite measurement. (C) Posterior view of buccal posterior crossbite for digital measurement. (D) Tooth width measurement in Digicast®. (E) Preparation of the ideal arch to determine the required space. (F) Digicast® section to digitally measure crowding.**  
Figure 2: Digital tracing with the Dolphin Imaging Software 9.0.  
The discrepancy index was measured according to the instructions published on the website [[https://www.americanboardortho.com](https://www.americanboardortho.com)]([https://www.americanboardortho.com](https://www.americanboardortho.com)), last updated on 3 August 2015 and accessed June 2020. The sections that were evaluated to obtain the final discrepancy index score and the techniques used to complete its various sections are shown in Table 1.  
Figure 4: Manual tracing using printed radiograph and tracing ruler.  
Figure 3: (**A**,**B**) Manual overjet and overbite measurement. (**C**) Posterior view of buccal posterior crossbite for manual measurement. (**D**–**F**) Manual measurement of crowding.