J Oral Maxillofac Surg

69:e549-e557, 2011

Three-Dimensional Reconstruction of
Maxillae Using Spiral Computed
Tomography and Its Application in
Postoperative Adult Patients With
Unilateral Complete Cleft Lip and Palate
HongQuan Li, MM,* YuSheng Yang, PhD, MD,†
Yang Chen, PhD, MD,‡ YiLai Wu, MM,§ Yong Zhang, MM,¶
DanDan Wu, MM,储 and Yun Liang, MM#

Purpose: To establish a method to analyze malformed maxillae of postoperative adult patients with
unilateral complete cleft lip and palate in 3 dimensions.
Materials and Methods: A total of 35 landmarks were defined and used to reconstruct 3-dimensional
maxillary images of healthy Chinese Han subjects and 30 postoperative Chinese Han adult patients (17
men and 13 women, with mean age of 19.07 years) with unilateral complete cleft lip and palate. This was
done using spiral computed tomography, and their corresponding parameters were analyzed using
SimPlant software, version 11.04, and compared by t test using SAS software, version 6.12.
Results: Of the 7 centered landmarks, A and ANS in the patients were obviously deviated to the
nonoperative side (P ⬍ .01) and the symmetrical landmark pairs INM=-INM, SNM=-SNM and SPr=-SPr, but
not MA=-MA, SoF=-SoF, and LPAC-LPA in the infraorbital region and piriform aperture peritreme in healthy
subjects were shifted toward the coordinate sagittal plane S. The data also showed that the maxillae in
the patients’ operative side were hypoplastic, especially in the posteroanterior direction compared with
the nonoperative side and healthy subjects.
Conclusions: The proposed method can precisely measure the distances of the maxillary landmarks to
3-dimensional coordinates and has application potential in evaluating maxillary deformity in patients with
postoperative unilateral complete cleft lip and palate.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:e549-e557, 2011

In the past decades, confined by the technology and
medical apparatus, maxillary morphologic abnormal-
ity was illustrated as a scrambled 3-dimensional (3D)
structure projected by 2-dimensional radiographic lat-
eral and posteroanterior cephalometry.1-4 However,
these methods have proved to be inaccurate.3 With
the advances in medical science and imaging tech-
niques, 3D computed tomography (CT) reconstruc-
tion of stereoscopic measurement has begun to be
used to study the craniomaxillofacial structure.5,6 Kim
et al7 studied 3D images of the human skull using
multislice spiral CT and evaluated the effect of scan

Received from the Department of Oral and Maxillofacial Surgery, This study was supported by Shanghai Leading Academic Disci-
Shanghai Ninth People’s Hospital, affiliated with Shanghai Jiao pline Project (Project Number: S30206).
Tong University School of Medicine, Shanghai Key Laboratory of Address correspondence and reprint requests to Dr Yang: De-
Stomatology, Shanghai, People’s Republic of China. partment of Oral and Maxillofacial Surgery, Ninth People’s Hospi-
*Resident Doctor. tal, affiliated with Shanghai Jiao Tong University School of Medi-
†Associate Professor. cine, 639 Zhi Zao Ju Road, Shanghai 200011 China; e-mail:
‡Associate Professor. Yysdj4829@yahoo.com.cn.
§Attending Doctor. © 2011 American Association of Oral and Maxillofacial Surgeons
¶Attending Doctor. 0278-2391/11/6912-0031$36.00/0
储Resident Doctor.
doi:10.1016/j.joms.2011.07.024
#Resident Doctor.

e549
e550
slice thickness on the 3D images. Badawi-Fayad and
Cabanis8 studied the configuration characteristics of
human craniomaxillofacial osseous tissue and con-
cluded that 3D-CT measurement has excellent repeat-
ability and superior accuracy. Solar et al9 defined the
landmarks, lines, planes, coherent lineal distances,
angles, and indexes using a skull image model recon-
structed using spiral 3D-CT images of healthy subjects
and software and found the measurement is repeat-
able and reliable. Using multidetector CT and cone-
beam CT, heads can be imaged at 360° in 0.5 second
with 0.5-mm resolution with less radiation dosage.10
Because of its high quantitative accuracy, 3D-CT re-
construction has become an irreplaceable quantita-
tive method for the treatment of craniomaxillofacial
malformation,9,11 and its application in the measure-
ment of craniomaxillofacial soft and hard tissues has
increased enormously.12-15
The present report proposes a new spiral 3D-CT
method for reconstructing 3D images of the maxillae
using 30 healthy subjects and SimPlant software, ver-
sion 11.04 (Materialise, Leuven, Belgium). The study
used the method in the measurement of the maxillary
malposition and malformation of 30 adult patients
who had unilateral complete cleft lip and palate op-
eration and compared the data between the healthy
subjects and the patients.
Materials and Methods
PATIENTS
A total of 30 Chinese Han adult inpatients who had
undergone unilateral complete cleft lip and palate
surgery to treat a nasolabial deformity at the oral and
maxillofacial surgery department (Shanghai Ninth
People’s Hospital, Shanghai, China) were enrolled in
the present study. All the subjects had been born with
complete unilateral, nonsyndromic cleft lip and pal-
ate. The cleft lip had been repaired at 10 months of
age using Millard’s rotation and an advancement flap
technique, and the cleft palates had been repaired at
2.5 years of age using a 2-flap push back palatoplasty.
The subjects who had undergone any other cleft lip-
and palate-related surgery and prosthetic repair, had a
history of alveolar cleft bone graft, plastic surgery,
oral and maxillofacial orthognathic surgery, orthodon-
tic treatment and denture placement, or had other
diseases in the maxillofacial region were excluded. Of
the included subjects, 17 were men aged 17 to 24
years (average 19.06) and 13 were women aged 16 to
22 years (average 19.08); 15 subjects (average age
18.80 years) had undergone surgery on the left side
and 15 (average age 19.33 years) on the right side.
In addition, 30 healthy subjects with a similar age
and gender distribution were recruited for the pres-
3D RECONSTRUCTION OF MAXILLAE USING SPIRAL CT
ent study. The Shanghai Ninth People’s Hospital eth-
ics committee approved the present study, which was
performed according to the principles of the Decla-
ration of Helsinki. All subjects provided informed con-
sent for the study.
SPIRAL CT SCANNING
All subjects were placed statically in the supine
position with the facial midline coinciding with the
long axis of the CT machine on the Frankfort horizon-
tal plane perpendicular to the floor. CT scanning was
performed using a LightSpeed Ultra 6 CT scanner (GE
Medical System, Phil Phil DE city, CT, USA) using a
high-resolution bone algorithm with a slice thickness/
layer spacing of 1.25 mm/1.25 mm in the axial and
coronal plane C and a pitch of 1.35 mm at 120.0 kV
and 250 mA. The image covered the areas from the
basis cranii to the inferior border of the mandibular
body and had a pixel matrix of 512 ⫻ 512.
3D IMAGE RECONSTRUCTION, LANDMARK
IDENTIFICATION, COORDINATE SYSTEM
ESTABLISHMENT, AND DATA ACQUISITION
The axial images were reconstructed into a 3D
video model using SimPlant, version 11.04, software
(Materialise). All 35 landmarks, as defined in Table 1
and illustrated in Fig 1A, were first designated on the
surface of the 3D video model, and their positions
were then verified in the multiple planar reformat
mode. Some points were more important to show
symmetry of the operative side and nonoperative side
of the postoperative adult patients’ infraorbital region
and piriform aperture peritreme, such as the point
sets of LPAC and LPA, MA= and MA, SoF= and SoF, and
INM= and INM (Fig 1B).
The coordinate system used in the present study
was established as follows: 1) the central point of the
sella (Se) in the 3D image was defined as the origin of
the 3D coordinate system; 2) the plane containing
point Se and parallel to the Frankfort horizontal plane,
which was constructed by the Po points at both
operative and nonoperative sides and point or on the
left side, was defined as the horizontal reference
plane H and its positive direction was toward the left
side of patients; 3) the plane containing the points Se
and N and perpendicular to the horizontal plane H
was defined as the midsagittal plane S, and its positive
direction was toward the posteroanterior side of the
patients; and 4) the plane containing point Se and
perpendicular to the horizontal plane H and the mid-
sagittal plane S was defined as coronal plane C, and its
positive direction was toward the downward side of
patients. This coordinate system was defined as the
standard 3D coordinate system.
SimPlant software is an interactive computer-aided
design system designed by Materialise (Leuven, Bel-
LI ET AL e551

Table 1. LANDMARKS USED IN PRESENT STUDY

calculate the linear distances and angles. Because the
software has powerful 3D tools, the results were
Landmarks Definition immediately displayed on the screen after landmarks,
A Most posterior point on profile of lines, planes, distances, and angles were defined, and
maxilla between anterior nasal spine the landmarks were designated on the surface of the
and alveolar crest 3D video model. In the present study, the distances of
A2 Most inferior anterior point of alveolar all 35 landmarks marked on 3D maxillary video mod-
crest between upper central incisors
ANB Most anterior point of nasal bone suture els to 3D coordinate planes were measured, analyzed,
ANS Most anterior midpoint of anterior nasal and recorded as mean value ⫾ standard error. In
spine addition, the distances of the centered landmarks to
Ba Median point on anterior edge of the midsagittal plane S and the distances of median
foramen magnum
N Intersection of internasal suture with zygomorphic landmarks to the 3D coordinate planes
nasofrontal suture were measured and analyzed. The asymmetry ratios
Se Midpoint of sella turcica and relative shifts of symmetry landmarks on the op-
INM Most inferior point on nasomaxillary erative side and the nonoperative side of the 30 pa-
suture
LPA Intersection of lateral border of piriform tients’ maxillae were also analyzed.
aperture and plane parallel to sagittal The distances of every landmark to 3D coordinate
plane S on nonoperative side planes in 30 patients were correspondingly compared
LPAC Intersection of lateral border of piriform with those of the 30 healthy subjects. The relative
aperture and plane parallel to sagittal
plane S on operative side or on right shift and direction of each landmark were discussed.
side of healthy subjects
MA MA (anterior maxillary point) is
intersection of maxillary anterior
parietal and intersection line of plane
containing point SoF and parallel to
sagittal plane S and plane containing
point Zm and parallel to horizontal
plane H
MT Most posterior inferior point on
maxillary tuberosity
Mx (maxillae) Lowermost point on zygomaticoalveolar
ridge
Or (orbitale) Lowest point on infraorbital edge
P (porion) Uppermost point on bony external
auditory meatus
SNM Most superior point on nasomaxillary
suture
SoF Midpoint of suborbital foramen
SPC Midpoint of labial alveolar crest of
maxillary canine
SPM Midpoint of first superior molar tooth
on buccal alveolar crest
SPr Midpoint of superior incisor on labial
alveolar crest
Z Most interior point on
zygomaticofrontal suture
Zm Most inferior point on
zygomaticomaxillary suture
Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral
Maxillofac Surg 2011.

gium) for precisely planning the clinical operation

using the spiral CT data. Its accuracy and clinical
applicability have been proven by enforceability vali-
dation of the European Union Validation Institution.
Consequently, its accuracy in 3D video model mea- FIGURE 1. Schematic of landmarks of patients. A, All landmarks;
surement, and the general measurement was not fur- B, important symmetrical landmarks and central landmarks.
ther validated. In the present study, the SimPlant Pro, Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral
version 11.04, was used to automatically measure and Maxillofac Surg 2011.
e552 3D RECONSTRUCTION OF MAXILLAE USING SPIRAL CT

FIGURE 2. A, Schematic of centered landmarks; B, median zygo-
morphic landmarks.
Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral
Maxillofac Surg 2011.
STATISTICAL ANALYSIS
The obtained data were collected, arranged using
Microsoft Office Excel 2003 (Microsoft, Redmond,
WA), and analyzed using the t test in the SAS statistical
package, version 6.12 (SAS Institute, Cary, NC). P ⬍
.05 was considered statistically significant.
Results
We first assessed the reproducibility of the land-
marks. All landmarks of a randomly selected group of
healthy subjects were identified once at the beginning
of the study and identified again 2 weeks later by the
same operator (L.H.Q.). The difference between the
assessments was examined using the paired t test and
SAS, version 6.12 (SAS Institute). The P values for all
the landmarks were greater than 0.05, indicating that
all landmarks could be reproducibly identified.
Under ideal circumstances, the distances from the
centered landmarks on the maxilla to the midsagittal
plane S should be 0, and ANB, ANS, A, and A2 should
be on the maxillary median structures at the superior
and inferior piriform aperture peritreme (Fig 2A). The
landmarks A and ANS of the 30 patients were obvi-
ously shifted toward the nonoperative side (P ⬍ .01),
and A2, ANB, and Ba were not shifted and should be
considered in the midsagittal plane S (P ⬎ .05; Table
2). The N and Se points were defined in the midsag-
ittal plane S and thus were not discussed.
Under ideal circumstances, the difference between
the distances from every median zygomorphic land-
mark of the maxilla to the 3D coordinates should be
0 and the distribution of LPA and LPAC, MA= and MA,
SoF= and SoF, INM= and INM at the infraorbital region
and piriform aperture peritreme (Fig 2B) should be
symmetric. However, the obtained data listed in Table
3 clearly indicate that 1) landmark INM= and its cor-
responding INM in the piriform aperture peritreme
were obviously asymmetrical in all 3 directions; 2) the
distances of the landmarks LPAC, SPC=, and Zm= to
coronal plane C were obviously different from those
of their corresponding LPA, SPC, and Zm; 3) the
distances of the landmarks SoF= and SpR= to horizon-
tal plane H were not equal to those of their corre-
sponding SoF and SpR; 4) the distance of landmark
Mx= to midsagittal plane S varied from that of its
corresponding Mx; and 5) the distances of landmark

Table 2. DISTANCE COMPARISON OF CENTERED LANDMARKS TO 3-DIMENSIONAL COORDINATE PLANES

Mean Distance ⫾ SE (mm) P Value (t Test)

Landmark C H S C H S

A 63.10 ⫾ 3.95 46.62 ⫾ 3.45 1.76 ⫾ 1.78 — — ⬍.0001*

A2 65.15 ⫾ 4.62 57.99 ⫾ 5.12 ⫺0.84 ⫾ 2.57 — — .0835
ANB 73.63 ⫾ 3.87 14.47 ⫾ 3.58 0.44 ⫾ 1.59 — — .1399
ANS 65.74 ⫾ 4.09 40.30 ⫾ 6.89 2.46 ⫾ 2.50 — — ⬍.0001*
Ba 24.93 ⫾ 3.00 37.95 ⫾ 2.72 0.20 ⫾ 1.68 — — .5186
N 63.56 ⫾ 2.94 10.30 ⫾ 2.85 0⫾0 — — —
Se 0⫾0 0⫾0 0⫾0 — — —
Abbreviations: SE, standard error; C, coronal plane; H, horizontal plane; S, sagittal plane.
*Statistically significant.
Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral Maxillofac Surg 2011.
LI ET AL e553

Table 3. DISTANCE COMPARISON OF SYMMETRIC LANDMARKS ON OPERATIVE AND NONOPERATIVE SIDES TO

3-DIMENSIONAL COORDINATE PLANES

Difference in Mean Distance ⫾ SE (mm) P Value (t Test)

Landmark C H S C H S

INM=-INM ⫺0.53 ⫾ 1.32 1.09 ⫾ 1.27 ⫺0.98 ⫾ 2.52 .0367* ⬍.0001† .0420*
LPAC-LPA ⫺2.60 ⫾ 2.21 0.03 ⫾ 0.23 0.23 ⫾ 2.66 ⬍.0001† .5437 .6447
MA=-MA ⫺2.60 ⫾ 7.79 0.01 ⫾ 1.51 0.13 ⫾ 2.37 .0782 .9684 .7692
MT=-MT ⫺1.14 ⫾ 1.51 ⫺0.20 ⫾ 1.48 1.22 ⫾ 2.52 .0003† .4690 .0130*
Mx=-Mx ⫺0.27 ⫾ 2.55 ⫺0.18 ⫾ 1.25 0.82 ⫾ 2.16 .5711 .4408 .0480*
Or=-Or ⫺0.22 ⫾ 1.70 0.24 ⫾ 1.14 ⫺1.00 ⫾ 5.26 .4852 .2506 .3090
P=-P ⫺0.44 ⫾ 2.68 0.00 ⫾ 0.01 ⫺0.48 ⫾ 2.38 .3754 .3256 .2729
SNM=-SNM 0.08 ⫾ 0.78 ⫺0.03 ⫾ 0.57 ⫺2.20 ⫾ 6.89 .5686 .7567 .0906
SoF=-SoF ⫺0.42 ⫾ 1.61 ⫺0.70 ⫾ 1.51 0.15 ⫾ 2.40 .1628 .0165* .7322
SPC=-SPC ⫺1.17 ⫾ 1.65 ⫺2.75 ⫾ 8.62 0.89 ⫾ 3.75 .0006† .0909 .2053
SPM=-SPM ⫺0.80 ⫾ 2.26 ⫺0.44 ⫾ 1.55 1.96 ⫾ 5.25 .0620 .1284 .0501
SPr=-SPr 0.07 ⫾ 1.04 ⫺1.03 ⫾ 1.02 1.25 ⫾ 5.08 .7179 ⬍.000† .1880
Z=-Z 0.02 ⫾ 2.31 ⫺0.14 ⫾ 1.27 ⫺1.21 ⫾ 7.28 .9700 .5626 .3718
Zm=-Zm ⫺1.10 ⫾ 2.26 0.01 ⫾ 1.52 0.50 ⫾ 2.56 .0122* .9695 .2891
Abbreviations as in Table 2.
*Statistically significant.
†Extremely statistically significant.
Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral Maxillofac Surg 2011.

MT= to both coronal plane C and midsagittal plane S the median zygomorphic landmarks located in the
were different from its correspondence. However, maxillary periphery on the operative and nonopera-
landmark MA was symmetrical to its corresponding tive sides and MA=-MA, SoF=-SoF, and LPAC-LPA in the
MA= in all 3 directions. infraorbital region and piriform aperture peritreme
The asymmetry ratios of the median zygomorphic were symmetrical in the 3D directions, and INM=-
landmarks of the 30 patients were calculated accord- INM, SNM=-SNM, and SPr=-SPr were obviously asym-
ing to Japanese scholar Katox’s asymmetry ratio con- metrical in the horizontal direction.
cept and calculation formula.16 As listed in Table 4, The shifts of the median zygomorphic landmarks
on the operative side relative to their corresponding
landmarks on the nonoperative side could be ana-
Table 4. ASYMMETRICAL RATIO OF SYMMETRICAL lyzed based on the differences between their mean
LANDMARKS OF POSTOPERATIVE ADULT PATIENTS
WITH UNILATERAL COMPLETE CLEFT LIP AND PALATE 3D distances (Table 5). A positive value in distance
indicates that the landmark on the operative side has
Asymmetry Ratio of Patients With shifted forward, downward, or outward compared
Unilateral Surgery with its corresponding landmarks on the nonopera-
Landmark QC QH QS tive side. In contrast, a negative value in distance
INM=-INM 0.0078 0.0545 0.1141* indicates that the landmark on the operative side
LPAC-LPA 0.0436 0.0008 0.0175 shifts backward, upward, or inward to the nonopera-
MA=-MA 0.0530 0.0003 0.0045 tive side. Because P= and P are located at the posterior
MT=-MT 0.0692 0.0039 0.0468 of the coronal plane C, a positive difference in the
Mx=-Mx 0.0067 0.0042 0.0222
distances of P= and P to plane C means that P= relative
Or=-Or 0.0040 0.0138 0.0289
P=-P 0.0178 0.0001 0.0080 to P shifts backward, otherwise forward. Similarly,
SNM=-SNM 0.0013 0.0045 0.2977* positive differences in the distances between SNM=
SoF=-SoF 0.0077 0.0281 0.0053 and SNM and Z’ and Z to plane H indicate that SNM=
SPC=-SPC 0.0195 0.0476 0.0474 and Z= relative to SNM or Z shift upward, otherwise
SPM=-SPM 0.0200 0.0077 0.0650
SPr=-SPr 0.0011 0.0181 0.2717*
downward. Our results show that 1) INM= on the
Z=-Z 0.0003 0.0229 0.0250 operative side shifted backward, downward, and in-
Zm=-Zm 0.0273 0.0003 0.0105 ward compared with INM on the nonoperative side;
2) LPAC, SPC=, and Zm= shifted to the posterior rela-
Abbreviations: Q, Asymmetry ratio; other abbreviations as
in Table 2. tive to LPA, SPC, and Zm, respectively; 3) SoF= and
*Statistically significant. SPr= shifted upward relative to SoF and SPr, respec-
Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral tively; 4) Mx= shifted upward and outward relative to
Maxillofac Surg 2011. Mx; and 5) MT= shifted backward and outward rela-
e554 3D RECONSTRUCTION OF MAXILLAE USING SPIRAL CT

tive to MT. However, MA= did not shift relative to MA
in all 3 directions.
The grouped t test of the mean distances of all
corresponding maxillary landmarks in the 30 patients
and 30 healthy subjects showed that the number of
landmarks on the patients’ maxillae with different
distances to coronal plane C from healthy subjects
was greater than that to sagittal plane S. Only the
mean distance of landmark ANB to the horizontal
plane H was significantly different statistically be-
tween the patients and healthy subjects, indicating
that the mean height of the 30 patients’ maxillae was
not significantly different statistically from that of the
healthy subjects. The shift of the landmarks between
the patients and healthy subjects was analyzed ac-
cording to the differences in the mean distances of all
landmarks to the 3 coordinates (Table 6). If the dif-
ference in the distance of the centered landmarks to
coronal plane C or horizontal plane H is positive, the
landmark of the patient shifts forward or downward;
otherwise, it shifts backward or upward. Because Ba
locates at the posterior of coronal plane C, a positive
difference in the mean distance from Ba to plane C
means that the landmark Ba of the patients relative to
Ba of the healthy subjects shifts backward; otherwise,
forward. Similarly, N locates superior of horizontal
plane H; thus, a positive difference in the mean dis-
tance from N to horizontal plane H means that the
patients’ N relative to that of the healthy subjects
shifts upward; otherwise downward. If a difference in
the distance of the centered landmarks to sagittal
plane S is positive, the landmark of the patients shifts
to the nonoperative side; otherwise to the operative
side. For those paired landmarks on the operative and
nonoperative sides, if the value of the patients sub-
tracted from that of the healthy subjects is positive,
the landmark of the patients relative to that of the
healthy subjects shifts forward, downward, or out-
ward; otherwise backward, upward, or inward. Be-
Therefore, we concluded that 1) the patients’ maxilla
relative to that of the healthy subjects was hypode-
veloped in the anteroposterior direction; 2) all cen-
tered landmarks near the fissure edge shifted back-
ward and downward to the nonoperative side; and 3)
all landmarks at the maxillary peripheral shifted back-
ward, downward, and outward.
The landmarks in the subregions are also discussed
according to Table 7. Single asterisks at the upper
right indicate a statistically significant difference be-
tween the patients and healthy subjects. Thus, the
maxillary peripheral landmarks on the patient’s oper-
ative side shifted backward and outward; the land-
marks on the patient’s nonoperative side shifted back-
ward; Ba had no obvious shift; and both P= and P
shifted outward. These results indicate that the pa-
tients’ maxilla on the operative and nonoperative
sides were hypodeveloped in the anteroposterior di-
rection, the width of the operative side increased, the
skull base had no abnormalities, and the temporalis
part widened. Landmarks on the central maxillary
region also shifted backward and outward, suggesting
hypodevelopment in the anteroposterior direction, an
increasing width, and a relatively stable infraorbital
margin on both sides without statistically significant
change. Among the landmarks above and below the
piriform aperture peritreme, the ANB shifted down-
ward, the ANS shifted backward toward the nonop-
erative side; the LPAC and LPA of the patients were
hypodeveloped in the anteroposterior direction, the
Table 5. MALPOSITION OF SYMMETRICAL
LANDMARKS ON OPERATIVE AND
NONOPERATIVE SIDES
Displacement Distance (mm) of
Landmark on Operative Side Relative
to Nonoperative Side
Landmark C H S

cause P= and P locate posterior of coronal plane C, a INM=-INM ⫺0.530* 1.094 †

⫺0.977*
positive difference in the distance of P= or P to C LPAC-LPA ⫺2.599† 0.026 0.227
indicates the landmark of the patients relative to that MA=-MA ⫺2.598 0.011 0.128
of the healthy subjects shifts backward; otherwise MT=-MT ⫺1.139† ⫺0.198 1.219*
Mx=-Mx ⫺0.267 ⫺0.178 0.815*
forward. For SNM=, SNM, Z=, and Z, which locate Or=-Or ⫺0.220 0.244 ⫺0.995
superior of horizontal plane H, a positive difference in P=-P 0.440 ⫺0.002 ⫺0.485
the distance of any of the 4 landmarks to H means the SNM=-SNM 0.082 ⫺0.033 ⫺2.201
landmark of the patients shifts upward relative to that SoF=-SoF ⫺0.420 ⫺0.701* 0.151
of the healthy subjects; otherwise downward. The SPC=-SPC ⫺1.167* ⫺2.752 0.888
SPM=-SPM ⫺0.801 ⫺0.443 1.959
explanation for Table 6 is listed in Table 7. SPr=-SPr 0.069 ⫺1.028† 1.251
From the data listed in Tables 6 and 7, the differ- Z=-Z 0.016 ⫺0.136 ⫺1.205
ences relative to the healthy subjects in the mean Zm=-Zm ⫺1.101* 0.011 0.504
distances of all landmarks to coronal plane C between Abbreviations as in Table 2.
the operative and nonoperative sides of the patients *Statistically significant.
were negative, indicating all landmarks of the patients †Extremely statistically significant.
shifted backward. Although the differences in Ba, P=, Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral
and P were positive, they still shifted backward. Maxillofac Surg 2011.
LI ET AL e555

Table 6. MEAN DISTANCE OF LANDMARKS TO 3-DIMENSIONAL COORDINATE PLANES AND THEIR MALPOSITION
IN PATIENTS COMPARED WITH HEALTHY SUBJECTS

Mean Distance (mm) Difference in Distance (mm)

Between Patients and Healthy
Patients Healthy Adults Subjects
Landmark C H S C H S C H S

A 63.10 46.62 1.76 65.98 46.60 0.19 ⫺2.88* 0.02 1.57*

A2 65.15 57.99 ⫺0.84 69.25 58.65 0.43 ⫺4.10* ⫺0.66 ⫺1.27†
ANB 73.63 14.47 0.44 74.03 12.30 0.25 ⫺0.40 2.17† 0.19
ANS 65.74 40.30 2.46 68.06 41.73 0.02 ⫺2.32† ⫺1.43 2.44*
Ba 24.93 37.95 0.20 24.21 37.40 0.43 0.72 0.55 ⫺0.23
N 63.56 10.30 0.00 63.91 11.37 0.00 ⫺0.35 ⫺1.07 0.00
Se 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
INM 67.77 18.98 8.56 68.82 18.35 8.11 ⫺1.05 0.63 0.45
LPA 59.67 31.39 12.71 61.57 31.79 12.08 ⫺1.90† ⫺0.40 0.64
MA 49.00 38.03 28.25 51.15 37.52 27.06 ⫺2.15† 0.51 1.19†
MT 16.45 50.19 24.84 18.67 49.73 24.37 ⫺2.22* 0.46 0.47
Mx 40.15 42.75 35.93 42.97 41.90 35.44 ⫺2.82* 0.85 0.49
Or 54.47 17.35 34.50 55.32 17.00 33.87 ⫺0.85 0.35 0.63
P 24.31 17.35 60.51 23.12 16.83 58.48 1.19 0.52 2.03†
SNM 61.49 7.32 7.39 62.00 7.84 4.49 ⫺0.51 ⫺0.52 2.90†
SoF 54.51 24.98 28.24 55.68 23.77 27.10 ⫺1.17 1.21 1.14†
SPC 59.98 57.83 17.84 62.90 57.03 19.09 ⫺2.92* 0.80 ⫺1.25*
SPM 40.06 57.42 28.20 42.55 56.67 29.37 ⫺2.49† 0.75 ⫺1.17
SPr 65.41 56.91 3.35 69.52 56.92 4.15 ⫺4.11* ⫺0.01 ⫺0.80
Z 48.14 5.96 48.13 49.18 6.27 47.50 ⫺1.04† ⫺0.31 0.63
Zm 40.34 38.09 47.39 43.19 37.51 46.42 ⫺2.85* 0.58 0.97
INM= 67.24 20.07 7.58 68.82 18.35 8.11 ⫺1.58† 1.72 ⫺0.53
LPAC 57.07 31.41 12.94 61.57 31.79 12.08 ⫺4.50* ⫺0.38 0.87†
MA= 46.40 38.05 28.38 51.15 37.52 27.06 ⫺4.75* 0.53 1.32†
MT= 15.32 50.00 26.06 18.67 49.73 24.37 ⫺3.35* 0.27 1.69†
Mx= 39.88 42.57 36.75 42.97 41.90 35.44 ⫺3.09* 0.67 1.31†
Or= 54.25 17.60 33.50 55.32 17.00 33.87 ⫺1.07 0.60 ⫺0.37
P= 24.75 17.35 60.03 23.12 16.83 58.48 1.63 0.52 1.55†
SNM= 61.57 7.29 5.19 62.00 7.84 4.49 ⫺0.43 ⫺0.55 0.70†
SoF= 54.09 24.28 28.39 55.68 23.77 27.10 ⫺1.59† 0.51 1.29†
SPC= 58.81 55.08 18.73 62.90 57.03 19.09 ⫺4.09* ⫺1.95 ⫺0.36
SPM= 39.26 56.97 30.16 42.55 56.67 29.37 ⫺3.29* 0.30 0.79
SPr= 65.48 55.88 4.60 69.52 56.92 4.15 ⫺4.04* ⫺1.04 0.45
Z= 48.15 5.82 46.92 49.18 6.27 47.50 ⫺1.03 ⫺0.45 0.58
Zm= 39.24 38.10 47.89 43.19 37.51 46.42 ⫺3.95* 0.59 1.47†
Abbreviations as in Table 2.
*Statistically significant.
†Extremely statistically significant.
Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral Maxillofac Surg 2011.

piriform aperture width at the level of LPAC widened, Discussion

and INM= shifted backward. Analyses of the landmarks
around the nasal bone showed that the superior part of
nasal bone had flattened and widened, the ANB had
shifted downward, and the nasal bone had lengthened.
Analyses of the landmarks of the alveolar ridge showed
that the maxilla on both sides were hypodeveloped,
consistent with the clinical signs of cross bite or scissors
bite in the patients. Analyses of the landmarks around
the fissure edge showed that the central line of the
maxilla was hypodeveloped in the anteroposterior di-
rection, ANS and A shifted toward the nonoperative
side, and A2 shifted toward the operative side.
In the present study, maxillary data were ob-
tained from patients who had undergone unilateral
complete cleft lip and palate operation and healthy
subjects using the same conditions of spiral CT
scanning. These data were used to reconstruct a 3D
maxillary video model with application of the Sim-
Plant, version 11.04, software. Selected landmarks
were defined, and their distances to the coordinates
of the established 3D model were measured, ana-
lyzed, and compared between the patients and
healthy subjects.
e556 3D RECONSTRUCTION OF MAXILLAE USING SPIRAL CT

Table 7. MALPOSITION DIRECTION OF PATIENTS’ LANDMARKS COMPARED WITH THAT OF HEALTHY ADULTS’

Patients Healthy Adults

S H C Landmarks C H S

A Backward* Downward Toward nonoperative

side*
A2 Backward* Upward Toward operative
side†
ANB Backward Downward† Toward nonoperative
side
ANS Backward Upward Toward nonoperative
side*
Ba Backward Downward Toward operative side
N Backward Downward —
Se — — —
Inward or toward Downward Backward† INM= INM Backward Downward Outward
nonoperative side
Outward† Upward Backward* LPAC LPA Backward† Upward Outward
Outward† Downward Backward* MA= MA Backward† Downward Outward†
Outward† Downward Backward* MT= MT Backward* Downward Outward
Outward† Downward Backward* Mx= Mx Backward* Downward Outward
Inward or toward Downward Backward Or= Or Backward Downward Outward
nonoperative side
Outward* Downward Backward P= P Backward Downward Outward†
Outward* Downward Backward SNM= SNM Backward Downward Outward†
Backward* Downward Backward† SoF= SoF Backward Downward Outward†
Inward or toward Upward Backward* SPC= SPC Backward* Downward Inward or toward
nonoperative side operative side*
Outward Downward Backward* SPM= SPM Backward† Downward Inward or toward
operative side
Outward Upward Backward* SPr= SPr Backward* Upward Inward or toward
Operation side
Inward or toward Downward Backward Z= Z Backward† Downward Outward
nonoperative side
Outward* Downward Backward* Zm= Zm Backward* Downward Outward
*Extremely statistically significant difference between patients and healthy subjects.
†Significant changes in landmarks between patients and healthy subjects.
Li et al. 3D Reconstruction of Maxillae Using Spiral CT. J Oral Maxillofac Surg 2011.

The repeatability of locating the landmarks was first
validated by comparing the identifications in the same
patients. The difference between the identifications
was not significant, with P ⬎ .05, suggesting good
repeatability and stability.
For patients who had undergone unilateral com-
plete cleft lip and palate surgery, the centered land-
marks A and ANS had obviously shifted to the nonop-
erative side; the remaining centered landmarks,
including the skull base median line, were still in the
sagittal S plane, shifting neither to the operative side
nor the nonoperative side. For symmetrical landmarks
in healthy subjects, those on the operative side were
hypodeveloped in the anteroposterior direction. The
landmark INM= had shifted to the posterior and infe-
rior directions and to the nonoperative side. Both
LPAC and LPA had obviously shifted backward to
coronal C plane but not to the sagittal S plane. SoF=
was hypodeveloped in the upper and lower direc-
tions; MA= and MA were obviously abnormal in all 3
dimensions. Most of the maxillary landmarks that
were symmetrical in the healthy subjects were still
symmetrical. For example, LPAC and LPA, MA= and
MA, SoF= and SoF were symmetrical in 3 dimensions
in all patients, but INM= and INM, SNM= and SNM, and
SPr= and SPr were asymmetrical to the sagittal S plane.
Compared with healthy subjects, the maxillae of pa-
tients on both operative and nonoperative sides were
hypodeveloped in the anteroposterior direction and the
width of the operative side had broadened. Those cen-
tered landmarks had also shifted backward and outward
and were hypodeveloped in the anteroposterior direc-
tion, although the infraorbital border was relatively sta-
ble and not obviously changed. The ANB had shifted
downward, the ANS had shifted backward and toward
the nonoperative side, the INM= had shifted backward,
the maxilla in LPAC and LPA was hypodeveloped in the
anteroposterior direction, and its width at LPAC was
widened. The superior part of the nasal bone on the
operative and nonoperative sides was widened, the in-
LI ET AL
ferior nasal bone on the operative side had shifted to the
anteroposterior direction, the nasal bridges of the pa-
tients had widened and extended downward. Bone
blocks on the alveolar ridge on the operative and non-
operative sides were both hypodeveloped in the antero-
posterior direction. All these results agree with the clin-
ical signs of cross bite or scissors bite occlusion in the
patients. Landmarks near the fissure edge showed a
hypodeveloped median line: the ANS and A had shifted
to the nonoperative side, although A2 had shifted to-
ward the operative side. The maxilla of the nonopera-
tive side was more obviously malpositioned than that of
the nonoperative side.
In conclusion, with the newest spiral 3D-CT recon-
struction and measurement method, we can use spe-
cific and strict data to demonstrate variations of the
maxilla on both operative and nonoperative sides of
adults who had unilateral complete cleft lip and palate
operation compared with healthy subjects. From the
data obtained from the measurements, we can clearly
recognize every patient’s maxillary malposition and
severity level from the 3D stereoscopic angle,17 pro-
viding us with a powerful tool to evaluate and study
the maxillary malformation of patients undergoing
unilateral complete cleft lip and palate surgery. By
accumulating long-term longitudinal data, we can es-
tablish more detailed standards to classify the malfor-
mation and provide better practical needs for patients
with nasolabial deformity.
Acknowledgment:
We would like to express our thanks to Professor Guofang Shen,
Department of Oral and Maxillofacial Surgery, Shanghai Ninth Peo-
ple’s Hospital, affiliated with Shanghai Jiao Tong University School
of Medicine, for his help.
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