Reproducibility of a three-dimensional skeletal-based craniofacial orientation method for virtual surgical planning

Published:December 09, 2021DOI:


      Inadequate craniofacial orientation of computed tomography (CT) scans can have significant implications in all three planes of space. The purpose of this study was to present the reproducibility of a 3-dimensional skeletal-based method of craniofacial orientation for virtual surgical planning. The protocol was defined by landmarks commonly used for cephalometry, and required identification of basion, nasion, right porion, and right orbitale, and navigation in all CT views (coronal, sagittal, and axial) for correction of yaw, roll, and pitch. Reproducibility of the method was assessed using eight CT scans that were randomly selected and anonymised. The observer group consisted of six oral and maxillofacial surgeons with varying levels of experience (resident or faculty) who performed craniofacial orientation according to the proposed method. Results were expected to be below 2° of variation, when overall accuracy as well as the influence of the academic level of the observers and symmetry of the evaluated anatomy, were considered as independent variables. Overall accuracy for all cases and for yaw, roll, and pitch were always below 2° of variation, without influence of level of experience and symmetry. Interobserver assessment was categorised as excellent in all instances, and intraobserver evaluation demonstrated consistency in the orientation of all axes. The proposed craniofacial orientation protocol presented in this study is easy to learn, applicable to computer-aided surgical planning, and can be performed by the non-technical clinician, resulting in excellent reproducibility and consistency.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to British Journal of Oral and Maxillofacial Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Leung M.Y.
        • Lo J.
        • Leung Y.Y.
        Accuracy of different modalities to record natural head position in 3 dimensions: a systematic review.
        J Oral Maxillofac Surg. 2016; 74: 2261-2284
        • Xia J.J.
        • Gateno J.
        • Teichgraeber J.F.
        • et al.
        Algorithm for planning a double-jaw orthognathic surgery using a computer-aided surgical simulation (CASS) protocol. Part 2: three-dimensional cephalometry.
        Int J Oral Maxillofac Surg. 2015; 44: 1441-1450
        • Kim D.S.
        • Yang H.J.
        • Huh K.H.
        • et al.
        Three-dimensional natural head position reproduction using a single facial photograph based on the POSIT method.
        J Craniomaxillofac Surg. 2014; 42: 1315-1321
        • Miloro M.
        • Borba A.M.
        • Ribeiro-Junior O.
        • et al.
        Is there consistency in cephalometric landmark identification amongst oral and maxillofacial surgeons?.
        Int J Oral Maxillofac Surg. 2014; 43: 445-453
        • Xia J.J.
        • Gateno J.
        • Teichgraeber J.F.
        • et al.
        Algorithm for planning a double-jaw orthognathic surgery using a computer-aided surgical simulation (CASS) protocol. Part 1: planning sequence.
        Int J Oral Maxillofac Surg. 2015; 44: 1431-1440
        • Zhu S.
        • Keeling A.
        • Hsung T.C.
        • et al.
        The difference between registered natural head position and estimated natural head position in three dimensions.
        Int J Oral Maxillofac Surg. 2018; 47: 276-282
        • Guijarro-Martínez R.
        • Swennen G.R.
        Three-dimensional cone beam computed tomography definition of the anatomical subregions of the upper airway: a validation study.
        Int J Oral Maxillofac Surg. 2013; 42: 1140-1149
        • Santos J.G.
        • Montezuma T.
        • Perez C.S.
        • et al.
        Body postural realignment in the first 2 months after orthognathic surgery.
        Am J Orthod Dentofacial Orthop. 2021; 159: e281-e290
        • Xia J.J.
        • Shevchenko L.
        • Gateno J.
        • et al.
        Outcome study of computer-aided surgical simulation in the treatment of patients with craniomaxillofacial deformities.
        J Oral Maxillofac Surg. 2011; 69: 2014-2024
        • Cassi D.
        • De Biase C.
        • Tonni I.
        • et al.
        Natural position of the head: review of two-dimensional and three-dimensional methods of recording.
        Br J Oral Maxillofac Surg. 2016; 54: 233-240
        • Rekawek P.
        • Rajapakse C.S.
        • Panchal N.
        Artificial intelligence: the future of maxillofacial prognosis and diagnosis?.
        J Oral Maxillofac Surg. 2021; 79: 1396-1397
        • Hughes G.N.
        • Gateño J.
        • English J.D.
        • et al.
        There is variability in our perception of the standard head orientation.
        Int J Oral Maxillofac Surg. 2017; 46: 1512-1516
        • Vernucci R.A.
        • Aghazada H.
        • Gardini K.
        • et al.
        Use of an anatomical mid-sagittal plane for 3-dimensional cephalometry: a preliminary study.
        Imaging Sci Dent. 2019; 49: 159-169
        • Yang H.J.
        • Han J.J.
        • Hwang S.J.
        Accuracy of 3D reproduction of natural head position using three different manual reorientation methods compared to 3D software.
        J Craniomaxillofac Surg. 2018; 46: 1625-1630
        • Frongia G.
        • Bracco P.
        • Piancino M.G.
        Three-dimensional cephalometry: a method for the identification and for the orientation of the skull after cone-bean computed tomographic scan.
        J Craniofac Surg. 2013; 24: e308-e311
        • Schatz E.C.
        • Xia J.J.
        • Gateno J.
        • et al.
        Development of a technique for recording and transferring natural head position in 3 dimensions.
        J Craniofac Surg. 2010; 21: 1452-1455