ORIGINAL ARTICLE

Three-dimensional analysis system

for orthognathic surgery patients
with jaw deformities
Masahiko Terajima,a Natsumi Yanagita,b Kanako Ozeki,b Yoshihiro Hoshino,b Noriko Mori,b
Tazuko K. Goto,c Kenji Tokumori,c Yoshimitsu Aoki,d and Akihiko Nakasimae
Fukuoka and Saitama, Japan
Introduction: Traditionally, lateral and frontal cephalograms are used with facial photographs to evaluate a
patients maxillofacial skeletal and facial soft-tissue morphology. However, the enlargement and distortion of
2-dimensional radiography made it difficult to accurately conceptualize the patients anatomy. The purpose
of this article was to introduce a new method for comparing 3-dimensional (3D) standard values of the
maxillofacial skeletal and facial soft-tissue morphology before and after orthognathic surgery. Methods:
Normative 3D standard values of the maxillofacial skeletal and facial soft-tissue morphology were calculated
from normal women. The pre- and postoperative morphology of one woman who underwent orthognathic
surgery was compared with the normative data. Results: This 3D analysis has clinical value to evaluate
patients before and after surgical treatment. Conclusions: This quantitative assessment of 3D maxillofacial
morphology can evaluate the area and degree of displacement and rotation of the facial skeleton and facial
soft tissues. This method is sufficiently useful for routine clinical applications. (Am J Orthod Dentofacial
Orthop 2008;134:100-11)

ncreasingly, orthognathic surgery is performed to

improve esthetics, function, and occlusal relationships.1 Traditionally, lateral and frontal cephalograms
and facial photographs have been used to evaluate a
patients maxillofacial skeletal and facial soft-tissue morphology, plan the operation, predict the final treatment
results, and evaluate the surgical outcome.
The cephalostat was introduced as a way to display
3-dimensional (3D) relationships.2 However, in lateral
and frontal cephalograms, many structures overlap
because complex 3D structures are projected onto a
2-dimensional (2D) surface. Although some important
a

Assistant professor, Department of Orthodontics, Faculty of Dentistry, Kyushu

University, Fukuoka, Japan.
b
Resident, Department of Orthodontics, Faculty of Dentistry, Kyushu University, Fukuoka, Japan.
c
Assistant professor, Department of Maxillofacial Radiology, Faculty of
Dentistry, Kyushu University, Fukuoka, Japan.
d
Associate professor, Department of Information Sciences, Faculty of Engineering, Shibaura Institute of Technology University, Saitama, Japan.
e
Professor and chair, Department of Orthodontics, Faculty of Dentistry,
Kyushu University, Fukuoka, Japan.
Partly supported by the Grant-in-Aid for Scientific Research (B) 12470462,
13557185, and Exploratory Research 14657546 from the Japan Society for the
Promotion of Science.
Reprint requests to: Masahiko Terajima, Kyushu University, Faculty of
Dentistry, Department of Orthodontics, Maidashi 3-1-1, Higashi-ku, Fukuoka
812-8582, Japan; e-mail, teraji@d7.dion.ne.jp.
Submitted, February 2006; revised and accepted, June 2006.
0889-5406/$34.00
Copyright 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.06.027

100

information is provided, it is difficult to conceptualize a

3D anomaly in living subjects.3,4
The current marked increase in the availability of
personal computers and powerful graphic workstations
provides great potential for complex image processing
and editing.4,5 Three-dimensional imaging techniques
such as computed tomography (CT), magnetic resonance imaging, and ultrasound have evolved greatly in
the last 2 decades; they show anatomic and pathologic
structures with high resolution.5,6 Specifically, the spiral/helical CT scanner acquires images with less scanning time, less radiation, and thinner section slices than
conventional CT,5,7 making life-size 3D images available in routine clinical practice. However, still missing
is a 3D normative database derived from the CT
images.
The purposes of this study were to (1) establish 3D
standard values of the maxillofacial skeletal and facial
soft-tissue morphology in normal Japanese women, (2)
create a 3D analyzing system for complex orthognathic
surgery based on linear measurements, and (3) test the
systems ability to compare preoperative and postoperative patient coordinates with standard values.
MATERIAL AND METHODS

CT images of the head were taken from 10 female

volunteers selected from the orthodontists and medical
staff of Kyushu University, Fukuoka, Japan. They

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 134, Number 1

Terajima et al 101

Fig 1. Definition of the coordinate system for the 3D CT reconstruction of the hard tissues. The z-x
plane is defined by the right and left porion and the average coordinate of the right and left orbitale.
The x-y plane is perpendicular to the z-x plane, passing through the right and left porion. The y-z
plane is perpendicular to the z-x and x-yplanes, passing through the average coordinate of the right
and left orbitale. A, View in the x and y planes of the 3D CT reconstruction of the soft and hard
tissues; B, view in the y and z planes of the same reconstruction.

ranged in age from 24 to 27 years, had well-balanced

faces, normal skull shapes, normal occlusions, and
well-arranged dentitions without prostheses. Before the
CT scanning, the subjects were fully informed about
the study; because of their medical training, they were
well aware of the risks of CT scans. The study was
approved by the Ethics Committee of the Faculty of
Dentistry, Kyushu University.
The CT scanner (Aquilion, Toshiba Medical, Tokyo, Japan) had a field of view of 240 mm, with an
output of 120 kV at 100 mA. Slice thickness was 1 mm.
During scanning, the subjects head was fixed, and the
slice plane was set parallel to the Frankfort horizontal
plane. The 2D slices started at the submandibular
region and covered the whole head, for a total of 241
slices. The CT slice data were transferred directly from
the scanner to a personal computer and modified by the
subtraction method to eliminate streak artifacts caused
by metal fillings in the teeth. To obtain an exact
rendering of the 3D visualization, we used imageprocessing software (Mimics Version 7.0, CDI, Tokyo,
Japan) to remove undesired objects in the contiguous
series of axial CT images (eg, streak artifacts). From
the CT data set, the hard and soft tissues of the
craniofacial structure were separated by threshold-

based segmentation, based on differences in their permeability to x-rays and visual interpretation of tissue
boundaries. Finally, the 3D CT images were constructed with 3D visualization software (Magics, CDI).
The 3D CT images were transferred to custom
image-measurement software (3-D-Rugle, Medic Engineering, Kyoto, Japan) in DXF format (Drawing Interchange File format). The 3D spatial coordinate system
(Fig 1) was defined by using 4 landmarks on the 3D CT
image of the hard tissue: right and left porion and right
and left orbitale. The z-x plane was defined by right
porion, left porion, and the average coordinate of right
and left orbitale. The x-y plane was perpendicular to the
z-x plane, passing through right and left porion. The y-z
plane was perpendicular to the z-x and x-y planes,
passing through the average of the coordinate of the
right and left orbitale.
After defining the 3D spatial coordinate system, the
original coordinates in the 3D CT images were transformed into the defined coordinate system. For each
subject in the normal group, 3D coordinates of 64
skeletal landmarks on the 3D CT image (Table I, Fig 2)
were measured by using the medical image-measurement software. The coordinates for bilateral points
were averaged in each subject, and means and standard

102 Terajima et al

Table I.

Definition of landmarks on the 3D CT of the hard tissue

Number

Landmark

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
15
16
17
18
18
19
19
20
20
21
21
22
22
23
23
24
24
25
25
26
26
27
27
28
28
29
29
30
30
31
31
32
32
33
33
34
34
35
35
36
36
37
37
38
38

V
GB
NA
R
ANS
A
PR
Id
B
Pog
Gn
Me
h1
h2
h3 (R)
h3 (L)
h4
h5
h6 (R)
h6 (L)
Po (R)
Po (L)
Or (R)
Or (L)
Or 1 (R)
Or 1 (L)
Or 2 (R)
Or 2 (L)
Or 3 (R)
Or 3 (L)
Or 4 (R)
Or 4 (L)
Eu (R)
Eu (L)
Zy (R)
Zy (L)
AP (R)
AP (L)
ZM (R)
ZM (L)
FZ (R)
FZ (L)
Fla (R)
Fla (L)
Co (R)
Co (L)
CP (R)
CP (L)
Go (R)
Go (L)
SIG (R)
SIG (L)
Ra (R)
Ra (L)
LO (R)
LO (L)
X1 (R)
X1 (L)
X2 (R)
X2 (L)

(R)
(L)

(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)

American Journal of Orthodontics and Dentofacial Orthopedics

July 2008

Operational definition
Vertex
Glabella
Nasion
Rhinion
Anterior nasal spine
Point A
Prosthion
Infradentale
Point B
Pogonion
Gnathion
Menton
Most anterior point of the lower side that divides the distance between vertex and glabella into 3 equal parts
Most posterior point of the lower side that divides the distance between vertex and glabella into 3 equal parts
Most external right point of the lower side that divides the distance between vertex and glabella into 3 equal parts
Most external left point of the lower side that divides the distance between vertex and glabella into 3 equal parts
Most anterior point of the upper side that the divides the distance between vertex and glabella into 3 equal parts
Most posterior point of the upper side that divides the distance between vertex and glabella into 3 equal parts
Most external right point of the upper side that divides the distance between vertex and glabella into 3 equal parts
Most external left point of the upper side that divides the distance between vertex and glabella into 3 equal parts
Porion (right)
Porion (left)
Orbitale (right)
Orbitale (left)
Upper inner edge of orbita (right)
Upper inner edge of orbita (left)
Upper outer edge of orbita (right)
Upper outer edge of orbita (left)
Lower outer edge of orbita (right)
Lower outer edge of orbita (left)
Lower inner edge of orbita (right)
Lower inner edge of orbita (left)
Euryon (right)
Euryon (left)
Zygion (right)
Zygion (left)
Apertura piriformis (right)
Apertura piriformis (left)
Zygomaticomaxillary suture (right)
Zygomaticomaxillary suture (left)
Frontozygomatic suture (right)
Frontozygomatic suture (left)
Facies lateralis (right)
Facies lateralis (left)
Condylion (right)
Condylion (left)
Coronoid process (right)
Coronoid process (left)
Gonion (right)
Gonion (left)
Sigmoid notch (right)
Sigmoid notch (left)
Anterior ramus (right)
Anterior ramus (left)
Oblique line of the mandible (right)
Oblique line of the mandible (left)
Upper point that divides the distance between condylion and gonion into 3 equal parts (right)
Upper point that divides the distance between condylion and gonion into 3 equal parts (left)
Lower point that divides the distance between condylion and gonion into 3 equal parts (right)
Lower point that divides the distance between condylion and gonion into 3 equal parts (left)

Terajima et al 103

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 134, Number 1

Table I.

Continued

Number

Landmark

39
39
40
40

X3
X3
X4
X4

(R)
(L)
(R)
(L)

(R)
(L)
(R)
(L)

Operational definition
Upper point that divides the distance between gonion and menton into 3 equal parts (right)
Upper point that divides the distance between gonion and menton into 3 equal parts (left)
Lower point that divides the distance between gonion and menton into 3 equal parts (right)
Lower point that divides the distance between gonion and menton into 3 equal parts (left)

Fig 2. Landmarks for the 3D CT reconstructions of the hard tissues. See Table I for details. A,
Lateral view; B, midsagittal section; C, frontal view; and D, lateral view of mandible.

104 Terajima et al

Table II.

Measurement lines

Abbreviation
X0
XR1
XR2
XR3
XR4
XL1
XL2
XL3
XL4
Y-1
Y0
Y1
Y2
Y3
Y4
Y5
Y6
Y7
Y8
Y9

American Journal of Orthodontics and Dentofacial Orthopedics

July 2008

Operational definition
Y-axis of the coordinate system in the 3D CT of
the hard tissue
Inner line that divides the distance between yaxis and point 9 into 4 equal parts
Line that divides the distance between y-axis
and point 9 into 2 equal parts
Outer line that divides the distance between yaxis and point 9 into 4 equal parts
Line through point 9
Inner line that divides the distance between yaxis and point 10 into 4 equal parts
Line that divides the distance between y-axis
and point 10 into 2 equal parts
Outer line that divides the distance between yaxis and point 10 into 4 equal parts
Line through point 10
Line through point 1
X-axis of the coordinate system in the 3D CT of
the hard tissue
Line through point 3
Line through point 4
Line through point 5
Line through point 6
Line through point 7
Upper line that divides the distance between
points 7 and 8 into 4 equal parts
Line that divides the distance between points 7
and 8 into 2 equal parts
Lower line that divides the distance between
points 7 and 8 into 4 equal parts
Line through point 8

deviations for each point were calculated between

subjects. Other landmarks, such as condylion and
gonion, were defined along a curvature and described
as intersection points.
For each subject, 10 anatomic measurement points
and 69 points of intersection of the 9 vertical planes
with the 11 horizontal planes were located on the 3D
CT facial soft-tissue image (Table II, Fig 3). Intersection points outside a subjects face were not used.
Means and standard deviations of the facial measurement points in the normal group were calculated and
used as the control values for analyses of facial morphology. The 9 vertical planes were defined as the
planes that divided the right and left facial outlines into
4 equal parts, from the midsagittal plane to the outlines
most external point.
A woman, aged 19 years, received a mandibular
setback with bilateral sagittal split ramus osteotomies
and presurgical and postsurgical orthodontics. The 3D
coordinates of the same maxillofacial skeletal and
facial soft-tissue points as in the normal group were
calculated on her 3D CT image according to the

Fig 3. Landmarks for the 3D CT reconstruction of the

soft tissues. See Table II for details. Points 1-10 indicate
anatomical measurement points on the face: 1, dorsum
of the nose (intersection between the y-axis and the line
passing through the right and left medial canthus); 2,
intersection point of the x- and y-axes; 3, pronasale; 4,
subnasale; 5, labrale superioris; 6, stomion; 7, labrale
inferioris; 8, soft-tissue menton; 9, the most external
point of the right facial outline; 10, the most external
point of the left facial outline.

methods above. Her preoperative and postoperative

data were compared with the normal groups data, and
her degree of maxillofacial deformity and her surgical
changes were analyzed 3 dimensionally.
RESULTS

Tables III and IV show the means and standard

deviations of the x, y, and z coordinates of the facial
skeleton and facial soft-tissue landmarks of the normative standard. It was possible to evaluate the 3D facial
skeletal and facial soft-tissue morphology simultaneously. When the patients preoperative data were
compared with the standard, the 3D relationships between the maxillofacial skeleton and facial soft tissues
were easily and precisely understood. Because the
results could be displayed numerically, it was possible
to locate the source of any deformity and determine its
3D magnitude for planning a surgical procedure.
Figure 4 shows the superimposed images of the
patients preoperative and postoperative maxillofacial
skeleton and facial soft tissues. The superimposed
images were registered by matching parts that were not
altered by surgery (ie, supraorbital and forehead regions). Figures 5 and 6 show comparisons of the facial
skeleton and soft-tissue coordinates between the patient
and the normative data in selected planes. Preoperatively, the line of the patients skeletal coordinates from

Terajima et al 105

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 134, Number 1

Table III.
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
15
16
17
18
18
19
19
20
20
21
21
22
22
23
23
24
24
25
25
26
26
27
27
28
28
29
29
30
30
31
31
32
32
33
33
34
34
35
35
36
36
37

(R)
(L)

(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)
(L)
(R)

Female normative data of the hard tissues (mm)

X-coordinate value
Mean

Y-coordinate value
SD

Z-coordinate value
Mean

SD

Mean

SD

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
69.9
69.9
0.0
0.0
58.2
58.2
60.3
60.3
30.8
30.8
18.4
18.4
37.8
37.8
40.6
40.6
13.6
13.6
72.2
72.2
64.9
64.9
11.3
11.3
37.8
37.8
50.0
50.0
56.0
56.0
49.9
49.9
47.5
47.5
47.5
47.5
49.2
49.2
42.5
42.5
41.4
41.4
53.6

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
1.6
1.6
0.0
0.0
2.0
2.0
2.5
2.5
2.1
2.1
1.8
1.8
2.9
2.9
1.1
1.1
1.5
1.5
1.7
1.7
1.7
1.7
0.8
0.8
2.1
2.1
1.2
1.2
1.6
1.6
1.6
1.6
0.7
0.7
2.6
2.6
2.1
2.1
1.2
1.2
1.4
1.4
3.2

118.6
41.0
26.4
4.7
24.6
30.8
38.3
61.8
69.7
80.5
84.0
87.2
66.6
66.6
66.6
66.6
92.4
92.4
92.4
92.4
0.0
0.0
0.0
0.0
34.9
34.9
33.3
33.3
2.5
2.5
5.6
5.6
44.5
44.5
0.5
0.5
14.1
14.1
22.5
22.5
26.7
26.7
5.1
5.1
0.4
0.4
7.2
7.2
55.0
55.0
17.7
17.7
34.7
34.7
42.3
42.3
18.0

4.6
2.1
1.3
2.9
2.5
1.8
2.6
2.7
4.8
3.4
3.4
3.3
1.8
1.8
1.8
1.8
3.0
3.0
3.0
3.0
0.0
0.0
0.0
0.0
1.7
1.7
2.1
2.1
1.1
1.1
1.4
1.4
4.4
4.4
1.4
1.4
1.9
1.9
2.2
2.2
2.8
2.8
2.0
2.0
1.9
1.9
3.5
3.5
4.2
4.2
3.6
3.6
2.4
2.4
3.2
3.2
2.4

0.4
88.5
86.7
97.0
90.0
86.6
89.8
84.2
78.6
78.0
77.2
76.5
83.7
80.6
3.9
3.9
66.4
66.8
8.5
8.5
0.0
0.0
76.3
76.3
82.9
82.9
78.8
78.8
74.2
74.2
82.0
82.0
0.5
0.5
32.5
32.5
83.8
83.8
64.5
64.5
64.3
64.3
54.8
54.8
14.7
14.7
45.7
45.7
19.6
19.6
29.4
29.4
42.7
42.7
43.8
43.8
15.0

4.7
5.2
4.5
3.9
4.4
4.8
4.6
4.9
6.2
6.7
6.8
8.1
5.5
6.0
4.4
4.4
5.7
6.3
4.3
4.3
0.0
0.0
2.6
2.6
4.7
4.7
4.2
4.2
3.6
3.6
3.4
3.4
3.8
3.8
4.2
4.2
4.7
4.7
4.1
4.1
4.1
4.1
2.2
2.2
2.0
2.0
2.9
2.9
6.3
6.3
2.7
2.7
4.7
4.7
4.8
4.8
3.1

106 Terajima et al

Table III.

Continued

Number
37
38
38
39
39
40
40

American Journal of Orthodontics and Dentofacial Orthopedics

July 2008

(L)
(R)
(L)
(R)
(L)
(R)
(L)

X-coordinate value
Mean

Y-coordinate value
SD

Z-coordinate value
Mean

SD

Mean

SD

53.6
49.4
49.4
41.4
41.4
28.5
28.5

3.2
2.3
2.3
2.9
2.9
5.5
5.5

18.0
36.5
36.5
63.3
63.3
78.2
78.2

2.4
3.3
3.3
4.1
4.1
5.5
5.5

15.0
19.1
19.1
39.0
39.0
56.6
56.6

3.1
6.0
6.0
8.7
8.7
6.3
6.3

glabella to prosthion was retruded. However, the chin

point and the mental region were protruded compared
with the normative data (Fig 5, A). The line of the
patients facial soft-tissue coordinates from the dorsum
of the nose to stomion was somewhat retruded in the
midline (Fig 6, A). Her lower lip and the mental region
protruded bilaterally compared with the controls, and
her left side protruded farther than her right side (Fig
6, B).
After surgery, the coordinate line of the maxillofacial skeleton from pogonion to menton was retruded
(Fig 5, A), and the surface coordinates in the midplane
of her facial soft tissues also moved back (Fig 6, A).
The upper cheek of her facial soft tissue was slightly
protruded at the XR1, XR2, XL1, and XL2 levels (Fig
6, D), but the lower cheek was retruded bilaterally (Fig
6, E and F). We could evaluate subtle changes in the
maxillofacial bones and soft tissues from the orthognathic surgery.
DISCUSSION

For many years, clinicians have used conventional

cephalograms to assess the maxillofacial skeleton and
the facial profile. After the introduction of the cephalostat, Broadbent2 stressed the necessity of coordinating standardized lateral and frontal cephalograms to
analyze craniofacial structures 3 dimensionally; 3D
information is still considered vitally important for
diagnosis and evaluation of treatment effects. However,
the enlargement and distortion produced by 2D radiography make it difficult to accurately represent all of the
patients anatomy.8,9 Therefore, there was a need to
develop methods to accurately acquire 3D information.4,10
The first commercial CT device was introduced in
1972, and it could precisely record and display the
shape of the maxillofacial region.11 In the early 1980s,
Marsh and Vannier12 developed 3D reconstruction
algorithms that generated a 3D image from a stack of
CT sections. Since then, many researchers6,13 have
used 3D imaging for studying craniofacial deformities

and discussed its effectiveness for understanding the

morphology and usefulness in quantitative analysis.14,15 Initially, the quality of the 3D images was poor,
and their clinical usefulness was limited.
Current spiral/helical CT scanners have a fast scanning speed so that motion artifacts, generated by
swallowing and respiration, are greatly reduced; less
radiation exposure is needed than with conventional
CT.5 The equipment can generate a series of thinner
sections, and the resolution of CT data is high. Hassfeld
et al16 experimentally determined the precision to be
between 0.3 and 0.5 mm.
In our previous study, Mori et al17 determined the
accuracy of 3D CT images of facial soft tissues. The
maximum error from the points on the model to the
corresponding points on the 3D CT images was 1.4
mm. This amount is small enough for spiral/helical 3D
CT imaging to be effectively used for precise 3D
quantification of skeletal deformities, such as facial
asymmetry, cleft lip and palate, and hemifacial microsomia, and the positions of the hard and soft tissues can
be extracted from the same sequential CT images.18,19
The success of complex surgical and orthodontic
procedures critically depends on careful and precise
treatment planning that uses 3D diagnostic information
of the maxillofacial skeleton and soft tissues.20,21
Moreover, 3D representation of facial appearance is of
paramount concern to patients, but the methods currently used to analyze skeletal relationships and facial
esthetics still rely on 2D lateral cephalograms and
photographs. Obviously, the disadvantage of such an
analysis is its limitation to 2 dimensions, making it
difficult to understand the 3D connection between the
maxillofacial skeletal and facial soft-tissue contours
simultaneously. For these reasons, we developed a
system for simultaneously analyzing the bones and
overlying soft tissues 3 dimensionally by plotting the
3D coordinates of the facial skeletal and soft-tissue
landmarks from the 3D CT images onto the same
coordinate axes.22 Hoshino et al23 reported that the 4
landmarks we used to define these axes are not affected

Terajima et al 107

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 134, Number 1

Table IV.

Female normative data of the soft tissues (mm)

Number

Landmark

X-coordinate value
Mean

Y-coordinate value
SD

Z -oordinate value
Mean

SD

Mean

SD

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58

XR4(Y1)
XR4(Y0)
XR3(Y1)
XR3(Y0)
XR3(Y1)
XR3(Y2)
XR3(Y3)
XR3(Y4)
XR2(Y1)
XR2(Y0)
XR2(Y1)
XR2(Y2)
XR2(Y3)
XR2(Y4)
XR2(Y5)
XR2(Y6)
XR1(Y1)
XR1(Y0)
XR1(Y1)
XR1(Y2)
XR1(Y3)
XR1(Y4)
XR1(Y5)
XR1(Y6)
XR1(Y7)
XR1(Y8)
XR0(Y1)
XR0(Y0)
XR0(Y1)
XR0(Y2)
XR0(Y3)
XR0(Y4)
XR0(Y5)
XR0(Y6)
XR0(Y7)
XR0(Y8)
XR0(Y9)
XL1(Y1)
XL1(Y0)
XL1(Y1)
XL1(Y2)
XL1(Y3)
XL1(Y4)
XL1(Y5)
XL1(Y6)
XL1(Y7)
XL1(Y8)
XL2(Y1)
XL2(Y0)
XL2(Y1)
XL2(Y2)
XL2(Y3)
XL2(Y4)
XL2(Y5)
XL2(Y6)
XL3(Y1)
XL3(Y0)
XL3(Y1)

73.0
73.0
54.8
54.8
54.8
54.8
54.8
54.8
36.7
36.7
36.7
36.7
36.7
36.7
36.7
36.7
18.4
18.4
18.4
18.4
18.4
18.4
18.4
18.4
18.4
18.4
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
18.4
18.4
18.4
18.4
18.4
18.4
18.4
18.4
18.4
18.4
36.7
36.7
36.7
36.7
36.7
36.7
36.7
36.7
54.8
54.8
54.8

2.4
2.4
1.7
1.7
1.7
1.7
1.7
1.7
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
0.8
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.7
1.7
1.7

14.2
0.0
14.2
0.0
15.8
28.5
40.6
49.8
14.2
0.0
15.8
28.5
40.6
49.8
60.1
68.5
14.2
0.0
15.8
28.5
40.6
49.8
60.1
68.5
76.6
84.9
14.2
0.0
15.8
28.5
40.6
49.8
60.1
68.5
76.6
84.8
92.9
14.2
0.0
15.8
28.5
40.6
49.8
60.1
68.5
76.6
84.9
14.2
0.0
15.8
28.5
40.6
49.8
60.1
68.5
14.2
0.0
15.8

1.4
0.0
1.4
0.0
3.1
2.5
3.9
2.4
1.4
0.0
3.1
2.5
3.9
2.4
2.5
2.7
1.4
0.0
3.1
2.5
3.9
2.4
2.5
2.7
3.2
3.7
1.4
0.0
3.1
2.5
3.9
2.4
2.5
2.7
3.2
3.7
4.3
1.4
0.0
3.1
2.5
3.9
2.4
2.5
2.7
3.2
3.7
1.4
0.0
3.1
2.5
3.9
2.4
2.5
2.7
1.4
0.0
3.1

34.1
28.1
69.1
59.2
77.1
72.5
65.6
59.9
85.3
67.8
86.8
85.0
81.6
78.7
73.8
68.5
84.1
92.5
90.0
89.7
94.0
88.5
88.6
84.7
82.6
78.9
93.0
102.2
110.6
97.3
100.5
93.9
97
92.9
85.5
81.5
72.6
84.1
92.5
90.0
89.7
94.0
88.5
88.6
84.7
82.6
78.9
85.3
68.7
86.8
85.0
81.6
78.7
73.8
68.5
69.1
59.2
77.1

7.4
7.5
4.4
8.8
5.4
5.5
6.3
6.2
4.1
8.2
4.9
4.9
4.9
4.9
5.8
6.6
4.2
4.6
5.4
4.6
4.4
5
4.9
5.7
6.4
7.2
4.5
3.9
4
3.9
3.9
4.2
4.7
5.3
6.6
7.4
9.5
4.2
4.6
5.4
4.6
4.4
5.0
4.9
5.7
6.4
7.2
4.1
8.2
4.9
4.9
4.9
4.9
5.8
6.6
4.4
8.8
5.4

108 Terajima et al

Table IV.

American Journal of Orthodontics and Dentofacial Orthopedics

July 2008

Continued

Number

Landmark

X-coordinate value
Mean

Y-coordinate value
SD

Z -oordinate value
Mean

SD

Mean

SD

59
60
61
62
63

XL3(Y2)
XL3(Y3)
XL3(Y4)
XL4(Y1)
XL4(Y0)

54.8
54.8
54.8
73.0
73.0

1.7
1.7
1.7
2.4
2.4

28.5
40.6
49.8
14.2
0.0

2.5
3.9
2.4
1.4
0.0

72.5
65.6
59.9
34.1
28.1

5.5
6.3
6.2
7.4
7.5

Fig 4. Preoperative and postoperative 3D CT images of the facial skeleton and facial soft tissues:
A, the superimposed images of the preoperative and postoperative facial skeleton; B, superimposed images of the facial soft tissues.

by small differences in the threshold settings. Accurate

3D coordinate axes could then be established on the 3D
CT image of the each maxillofacial skeleton, and the
scanned image could be precisely defined in space.
Ohta24 tried to establish standard 3D values of
facial morphology for orthognathic surgery by using a
noncontact 3D measuring apparatus. He compared the
3D values of the soft-tissue points on the patients face
with those in a normal group, but he did not have

normative data of the maxillofacial skeleton. Therefore,

he could not compare the 3D maxillofacial skeleton of
a patient to that of a normal control group.
In contrast, our analysis system provides a quantitative assessment of the 3D facial form and can
evaluate the area and degree of displacement and
rotation of both the maxillofacial skeleton and facial
soft tissues. For example, our system detected that the
patients mandible was asymmetrical, with deviation to

Terajima et al 109

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 134, Number 1

Fig 5. Comparisons of the facial skeleton between the normative data and the patients data: A, the
lines represent the y- and z-coordinate values of each set of landmarks at the midsagittal plane; B,
the lines represent the x- and y-coordinate values of each set of landmarks at the mandible; C, the
lines represent the x- and z-coordinate values of each set of landmarks at the mandible.

the left side. The facial soft tissue of the cheek was also
protruded on the left side (Fig 6, B). Orthognathic
surgery improved the facial asymmetry, although some
remained (Fig 6, C). This system effectively analyzed
the right and left sides separately, something that would
have been impossible with conventional cephalometric
analysis.
Having established the feasibility and accuracy of
our system, future studies with larger samples are
needed to establish its validity in the general population. Our method could then optimize surgical planning
for each patient, improving the precision and quality of
the surgical procedure. It could also help professional
colleagues to communicate with an interdisciplinary
treatment team and with patients.
In the future, a ratio of soft tissue to bone movement
in 3 dimensions could be measured, allowing prediction of

the 3D soft-tissue changes that result from surgical

changes of the underlying bone structure. We would also
like to construct curvilinear analyses of the facial skeletal
and soft-tissue morphology for more complete descriptions of complex craniofacial morphology, and develop
user-friendly 3D surgical planning and simulation software that includes soft-tissue changes. Another development could be a system for sending a patients image data
to a technician via the Internet for rapid 3D image
construction. Such packages would be a valuable tool in
many medical and dental applications.
CONCLUSIONS

We introduced a new 3D system for analyzing the

success of complex orthognathic surgery. Normative
3D standard values of the maxillofacial skeletal and
facial soft-tissue morphology were calculated from

110 Terajima et al

American Journal of Orthodontics and Dentofacial Orthopedics

July 2008

Fig 6. Comparisons of the facial soft tissue between the normative data and the patients data:
A, the lines represent the y- and z-coordinate values of each set of landmarks at the profile at
the midline (X0 line); B, the lines represent the y- and z-coordinates at the presurgical XR1 and
XL1 profile lines; C, the lines represent the y- and z-coordinates at the postsurgical XR1 and XL1
profile lines; D, the lines represent the x- and z-coordinate values of each set of landmarks at
the Y1 line; E, the lines represent the x- and z-coordinate values of each set of landmarks at the
Y4 line; F, the lines represent the x- and z-coordinate values of each set of landmarks at the Y6
line.

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 134, Number 1

normal women. The preoperative and postoperative

morphology of the woman who underwent orthognathic surgery (mandibular asymmetry correction and
setback) was compared with the newly derived normative data. This new 3D analysis has clinical value to
evaluate patients before and after surgical treatment.
Other diagnostic and treatment planning applications
are currently under investigation.
We thank the staff of the radiology and orthodontic
departments of the attached hospital of Kyushu University for their assistance in taking CTs and Haruaki
Hayasaki for reading the manuscript.

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