Accepted Manuscript

Postoperative outcomes of two- and three-dimensional planning in orthognathic

surgery: A comparative study

Ting-Yu Wu, Hsiu-Hsia Lin, Lun-Jou Lo, Cheng-Ting Ho

PII: S1748-6815(17)30165-1
DOI: 10.1016/[Link].2017.04.012
Reference: PRAS 5298

To appear in: Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 6 March 2017

Accepted Date: 14 April 2017

Please cite this article as: Wu T-Y, Lin H-H, Lo L-J, Ho C-T, Postoperative outcomes of two- and three-
dimensional planning in orthognathic surgery: A comparative study, British Journal of Plastic Surgery
(2017), doi: 10.1016/[Link].2017.04.012.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

Title: Postoperative outcomes of two- and three-dimensional planning in orthognathic

surgery: A comparative study

Ting-Yu Wu1, Hsiu-Hsia Lin2, Lun-Jou Lo3, Cheng-Ting Ho1,*

PT
RI
1
Department of Craniofacial Orthodontics, Department of Dentistry, Chang Gung

SC
Memorial Hospital, Taoyuan, Taiwan.

2
Department of Craniofacial Research Center, Chang Gung Memorial Hospital,

Taoyuan, Taiwan.
U
AN
3
Department of Plastic & Reconstructive Surgery, and Craniofacial Research Center,
M

Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.

D
TE

* Corresponding Author
EP

Cheng-Ting Ho, M.S. Department of Craniofacial Orthodontics, Department of

Dentistry, Chang Gung Memorial Hospital, Fu-Shin Street, Kwei Shan, Taoyuan,
C
AC

Taiwan 333. Tel: 886-3-3281200, ext 8318. Fax: 886-3-3281200-8320. Email:

ma2589@[Link]

1
 ACCEPTED MANUSCRIPT

Summary

Objective: Compared with conventional two-dimensional (2D) planning,

three-dimensional (3D) planning in orthognathic surgery yields more accurate

anatomical information and enables the precise positioning of maxillary and

PT
mandibular segments, particularly for patients with facial asymmetry. Accordingly,

RI
surgical outcomes achieved using 3D planning should be superior. This study

SC
determined the differences between the 2D and 3D planning techniques by comparing

U
their surgical outcomes.
AN
Materials and methods: In this retrospective study, patients who had undergone
M

surgery following the traditional 2D planning technique were classified into the 2D

planning group. Patients in whom the 2D plan was transferred to a 3D system after
D
TE

surgical simulation were classified into the 3D planning group. Surgical outcomes

were compared using cephalometric measurements and patient perception of the

EP

results.
C

Results: In the 3D planning group, more favorable results were observed in frontal
AC

symmetry, change in the angle between the orbital and occlusal lines, and frontal

ramus inclination, as well as in the distances from the mandibular central incisor and

menton to the midsagittal line. No significant differences were observed in the lateral

profiles (SNA, SNB, ANB and angle convexity) of the two groups. Patient

2
 ACCEPTED MANUSCRIPT

satisfaction was favorable in the two groups, but more patients in the 3D planning

group reported being very satisfied.

Conclusion: The 3D planning technique provided superior overall outcomes. The

study findings can be used to augment clinical planning and surgical execution when

PT
using a conventional approach.

RI
SC
KEYWORDS: Orthognathic surgery; Asymmetry; Surgical simulation

U
AN
M
D
TE
C EP
AC

3
 ACCEPTED MANUSCRIPT

Introduction

Conventional two-dimensional (2D) surgical planning in orthognathic surgery

(OGS) has long been used and remains prevalent. This planning technique involves

paper surgery using 2D cephalometry, model surgery on an articulator with a mounted

PT
dental cast, and manual fabrication of occlusal splints.1 2D radiography is easy to

RI
manipulate and involves less radiation exposure, less expenses, in addition to being

SC
easy to store, reproduce, and transport. However, the problems of magnification,

U
distortion, and difficulty of landmark registration exist.2 Limitations occur in the
AN
presentation and analysis of complex three-dimensional (3D) maxillofacial structures,
M

particularly for patients with major facial deformity or asymmetry.2-4 Model surgery

on the articulator can estimate the extent of yaw rotation but does not reveal the
D
TE

amount of bony interference with the pterygoid plate or between the bony segments.

Model surgery and occlusal stent fabrication are time consuming. Errors could occur
EP

in the registration of centric relation when mounting the dental cast on the articulator
C

through facebow transfer. When this 2D surgical plan is executed in the operating
AC

room, undetected problems could occur, such as bony collision in the ramus area,

discrepancy in the pitch–roll–yaw rotation, midline differences, genioplasty

inadequacies, and improper dental occlusions.5-8 An experienced surgeon may not

detect and rectify all problems during the operation, yielding unsatisfactory results.

4
 ACCEPTED MANUSCRIPT

Cone-beam computed tomography (CBCT) with a 3D presentation has become a

feasible and reliable method.9 Computer-aided surgical simulations by using CBCT

images have been adapted for OGS to facilitate cephalometric analysis, surgical

simulation, and splint fabrication.10-13 Compared with 2D X-ray images, 3D images

PT
register accurate anatomical information and enable precise quantitative

RI
measurements.14-18 For patients with facial asymmetry, a 3D model can demonstrate

SC
the extent of yaw rotation in the maxilla and mandible, occlusal plane canting, and

U
differential length of the mandibular body or ramus. After the superimposition of a
AN
digital dental model on CBCT images, a 3D model is available for analysis and
M

planning in OGS.19, 20

The 3D simulation method has been accepted for planning OGS, leading to
D
TE

significant improvements in surgical outcomes.21-23 Lin et al. proposed a protocol for

assessing the surgical simulation, positioning guides, intraoperative navigation, and

EP

outcome validation provided by computer-assisted surgical systems.24, 25 Badiali et al.

C

performed 3D virtual surgery combined with navigation and obtained favorable

AC

postoperative outcomes for maxillary repositioning.26, 27

Improvements in virtual

repositioning have gained wide popularity in OGS. A 2D plan was transferred to a 3D

system for surgical simulation, and the maxillomandibular movement was modified,

yielding ideal surgical outcomes.28 The 3D planning technique enabled achieving

5
 ACCEPTED MANUSCRIPT

changes in the dental midline, yaw and roll rotation, and ramus inclination, indicating

a potential insufficiency of the 2D planning technique.

However, few quantitative studies have investigated the differences in the

postoperative outcomes of the 2D and 3D planning techniques, although the 3D

PT
technique appears to be superior. The present study determined the aforementioned

RI
differences by comparing 2D and 3D planning in OGS.

U SC
Patients and Methods
AN
This retrospective study was conducted at the Craniofacial Research Center,
M

Chang Gung Memorial Hospital. Ethical approval was obtained from the Institutional

Review Board, Chang Gung Medical Foundation (IRB 103-2822 B). Figure 1
D
TE

presents the study flowchart.

Patient collection
EP

This study recruited 60 consecutive patients with class III malocclusion and facial
C

asymmetry who had undergone OGS from July 2013 to July 2015. The patients were
AC

classified into two groups according to their time of treatment: the first group (2D

planning group) comprised 18 women and 12 men aged 18–30 years (mean age, 23.5

years) who were treated using traditional 2D surgical planning from July 2013 to July

2014, and the second (3D planning group) comprised 22 women and 8 men aged 18–

6
 ACCEPTED MANUSCRIPT

26 years (mean age, 22.4 years) who were treated using 3D surgical planning from

August 2014 to July 2015. Patients with congenital or acquired deformities and

syndromes, facial cleft, or a history of trauma were excluded. All patients had a

concave facial profile, paranasal depression, mandibular prognathism, class III

PT
malocclusion, an inverse incisal relationship, a negative ANB angle, and facial

RI
asymmetry. The patients’ facial asymmetry was visible and characterized by occlusal

SC
plane canting, a discrepancy between the upper and lower dental midlines, cheek

U
asymmetry, and chin deviation.
AN
2D surgical planning
M

In the 2D planning group, all patients had received presurgical orthodontic

treatment, including leveling, alignment, arch coordination, and dental

D
TE

decompensation. 2D cephalograms, photographs, and dental casts were obtained 2

weeks preoperatively. 2D surgical planning was performed according to

EP

cephalometric measurements for OGS.29 Model surgery was performed according to

C

the surgical plan drawn from the aforementioned measurements, and the final occlusal
AC

splint was fabricated according to the planned maxillary and mandibular position. All

of these procedures were performed by the same orthodontist (CTH).

3D surgical planning

In the 3D planning group, all patients had received presurgical orthodontic

7
 ACCEPTED MANUSCRIPT

treatment, and records were collected in the same manner as in the 2D planning group.

Additionally, CBCT was performed 2 weeks preoperatively. Moreover, 3D

maxillofacial images were acquired using an i-CAT® CBCT scanner (Imaging

Sciences International, Hatfield, PA, USA) with a low-dose protocol and patient teeth

PT
under a light contact condition (120 kV, 5 mA, and 50 Hz). The extended field of view

RI
was 22 (height) × 16 (depth) cm, scanning time was 40 seconds, and voxel size was

SC
0.4 × 0.4 × 0.4 mm. The images were stored in Digital Imaging and Communications

U
in Medicine format and processed with a slice thickness of 0.4 mm. We obtained 3D
AN
images and the initial 3D virtual models by using CBCT data and the SimPlant O&O
M

(Materialize, Leuven, Belgium) or Dolphin (Dolphin Imaging and Management

Solutions, Chatsworth, California, USA) program. Through the segmentation function,

D
TE

the maxilla and mandible were outlined, and the dentition in 3D CBCT scans was

replaced and the virtual occlusion setup was derived. The 3D surgical planning was
EP

performed after the 2D plan was transferred to the 3D simulation system. The
C

Frankfort horizontal plane was used as the reference, and an initial virtual surgical
AC

model was developed. The position of the maxillomandibular complex (MMC) was

modified to devise a 3D plan.28 The revised positions of the maxilla, mandible, and

chin; occlusal canting; midline differences; and frontal ramus inclination were

decided by the surgeon and orthodontist according to the clinical evaluation and

8
 ACCEPTED MANUSCRIPT

normative 3D cephalometric data.30 The distal mandibular segment was moved to

occlude with the maxilla forming the MMC. The MMC image object was mobilized

to the planned position according to the initial 2D plan. The MMC position was

changed if it was found to be imperfect. The treatment team moved and rotated the

PT
MMC in the simulation system until the ideal position was achieved. The dental

RI
midline (translation) and occlusal plane (roll rotation) were first modified in the

SC
frontal view. Subsequently, the occlusal plane (pitch rotation) and facial profile were

U
adjusted in the lateral view. The basal view of the 3D image was referred to for
AN
verifying the symmetry of the cheek and collision between the ramus segments and
M

mandibular body contour (yaw rotation). The chin was moved as the last step for

facial esthetic purposes, if indicated.

D
TE

Surgical implementation

The surgery was performed according to the 2D and 3D plans for the respective
EP

groups by the same senior surgeon (LJL). Two-jaw OGS using a single (final)
C

occlusal splint was applied.31, 32 LeFort I and bilateral sagittal split osteotomy were
AC

also performed.21, 33
The maxillary and mandibular segments were placed in

intermaxillary fixation using the final occlusal splint, and the MMC was moved

according to the surgical plans. In the 3D planning group, positioning guides were

used to control the position of the MMC. These guides were designed using

9
 ACCEPTED MANUSCRIPT

computer-aided design software (Geomagic Wrap software, 3D System, USA) and

fabricated using a 3D printer (Objet30 OrthoDesk jets, Stratasys Ltd. Nasdaq: SSYS),

according to the maxillary position.24

Postoperative measurements

PT
Standard 2D cephalometric radiographs were obtained 2 weeks preoperatively

RI
and 1 month postoperatively for the 2D and 3D planning groups. Cephalometric

SC
radiographs were used for this comparative study because CBCT was not performed

U
for patients in the 2D group. The radiographs images were traced by the same
AN
clinician. Twenty-three hard tissue and four soft tissue landmarks were identified on
M

each cephalometric film to conduct 11 angular and 15 linear measurements. A line 7°

below the SN line (SN-7°) was defined as the horizontal reference and a line
D
TE

perpendicular to SN-7° through the nasion was used as the vertical reference for

lateral cephalometry. The line perpendicular to the orbital line through the crista galli
EP

was selected as the midsagittal line (MSL) in frontal cephalometric measurements.

C

The landmarks and measurements are defined in Tables 1 and 2 and Figures 2 and 3.
AC

The presurgical and postsurgical cephalograms were superimposed on the sella–

nasion (SN) line with both the sella and the orbital line with the crista galli serving as

the points of registration. The sagittal and vertical movements of the upper incisor

(U1), the mandibular central incisor (L1), point A, point B, and Pg were assessed to

10
 ACCEPTED MANUSCRIPT

analyze the anteroposterior changes. The transverse movements of U1, L1, and Me;

occlusal plane canting; and ramus inclination were measured to analyze the

translation changes and asymmetry correction. The differences in the surgical

outcomes of 2D and 3D planning were emphasized on sagittal and frontal changes,

PT
particularly the movements of midsagittal landmarks.

RI
Patient satisfaction

SC
The patients were inquired about their level of satisfaction with their facial

U
appearance 6 months postoperatively. Scores of 0, 1, 2, 3, and 4 represented “very
AN
unsatisfied,” “unsatisfied,” “acceptable,” “satisfied,” and “very satisfied,”
M

respectively.

Assessment of intraobserver and interobserver variability

D
TE

Thirty patients were randomly selected from all patients. All cephalometric

measurements were retraced and remeasured at an interval of 1 week. The angular and
EP

linear measurements were compared between the two time sets by using a paired t test.
C

To evaluate the intraobserver reproducibility and interobserver reliability of the

AC

measurements, the intraclass correlation coefficients (ICCs) of the errors as well as

the means and standard deviations were calculated.

Statistical methods

Independent sample t tests with and without the same variance were used to

11
 ACCEPTED MANUSCRIPT

compare the T2 (postoperative images) of the 2D and 3D planning groups. A paired t

test was used to test the amount of variations between preoperative (T1) and T2

within each group. Statistical significance was set at p < 0.05 (SPSS Version 15).

PT
Results

RI
In the cephalometric analysis, the ICCs of intraobserver and interobserver tests were

SC
0.816–0.998 (mean, 0.956) for the 2D planning group and 0.81–0.999 (mean, 0.963)

U
for the 3D planning group, respectively, indicating acceptable intraobserver
AN
reproducibility and interobserver reliability.
M

Table 3 shows the preoperative and postoperative cephalometric measurements and

a comparison of treatment changes and outcomes between the 2D and 3D planning

D
TE

groups. In all patients, a preoperative concave profile changed into a straight soft

tissue profile (angle convexity and incisor overjet changed from negative to positive),
EP

and the occlusal plane canting and chin deviation were observed to be decreasing
C

(measurement, approximately 0).

AC

The initial condition (2D T1 vs 3D T1) did not show significant differences

between the two groups. Considering T2 from the sagittal view, both the 3D and 2D

planning groups showed no statistically significant differences in the jaw bone

position (SNA, SNB, A to N vert, B to N vert, Pg to N vert, and angle convexity) and

12
 ACCEPTED MANUSCRIPT

dental relation ( incisor overjet, U1–SN and L1 to mandibular plane angle). However,

the 3D planning group showed superior T2 in terms of frontal symmetry because the

angular measurement of the orbital line to the occlusal line, ramus inclination, and the

linear measurements of both L1 and menton to the MSL were significantly closer to

PT
the reference value with regard to the correction of asymmetry.

RI
The T2 and T1 of the 2D and 3D planning groups were compared; the 3D

SC
planning group showed a larger amount of correction in the angle of the orbital line to

U
the occlusal line, frontal ramus inclination, and the distances from both L1 and
AN
menton to the MSL in the frontal view.
M

Table 4 and Figure 4 show a comparison of the perceptions of postoperative

improvement in the 2D and 3D planning groups. The results revealed that 90% of the
D
TE

patients were either very satisfied or satisfied with the surgical outcomes and facial

appearance, and 10% of the patients in the 3D planning group reported acceptable
EP

satisfaction. Moreover, 80% of the patients were very satisfied or satisfied with the
C

surgical outcomes, and 20% of the patients in the 2D planning group reported
AC

acceptable satisfaction. No patient reported being unsatisfied. The overall results

revealed no significant differences in patient satisfaction (p = 0.278). However, more

patients in the 3D group (47%) felt very satisfied than did those in the 2D group (20%;

p = 0.028). Figure 5 illustrates the profile and cephalometric changes of a 24-year-old

13
 ACCEPTED MANUSCRIPT

man who was treated using the 2D surgical plan, and Figure 6 demonstrates the

profile and cephalometric changes of a 22-year-old woman who was treated using the

3D surgical plan.

PT
Discussion

RI
Because of its acceptable cost and low radiation, 3D CBCT has been used more

SC
frequently for orthodontic diagnosis and orthognathic planning. Xia et al. and Gateno

U
et al. have developed a computer-aided surgical simulation system.34 They found that
AN
the surgical outcomes achieved using the surgical simulation method were superior to
M

those achieved using the traditional method. Trevor et al. revealed improved midline,

symmetry, and occlusion corrections in patients who underwent surgical simulation

D
TE

than those who underwent traditional preoperative model surgery.35 Lin et al. used

computer simulation in OGS and found it to be helpful in improving surgical planning,

EP

reducing surgical difficulty, facilitating the positioning and fixation of the bones.36
C

However, there is a lack of comparative and quantitative studies.

AC

Facial attractiveness is an important goal for patients undergoing OGS. An ideal

lateral profile and frontal symmetry are considered the evaluation standard of facial

appearance. Our study revealed that both planning systems were equally effective in

correcting the facial profile. No significant differences were observed in moving the

14
 ACCEPTED MANUSCRIPT

maxilla forward, moving the mandible backward, and repositioning the chin in both

groups. However, a comparison of T2 in terms of frontal symmetry showed that 3D

planning outperformed in the correction of midline deviation, ramus inclination

asymmetry, occlusal plane canting, and chin deviation; this is because the midsagittal

PT
landmarks (U1, L1, and Me) were much closer to the skeletal midline (0.35, 0.55, and

RI
1.20 mm, respectively), bilateral ramus inclination showed less variation (1.72°), and

SC
the occlusal and orbital lines were more parallel (0.62°) in the 3D planning group.

U
These changes are important for achieving better frontal symmetry and facial
AN
esthetics.
M

Notably, the 3D surgical plan in our study was developed from the revised 2D

surgical plan after surgical simulation. Therefore, the 3D plan was supposed to be
D
TE

more accurate than the 2D plan. Remarkably, a comparison of T2 and T1 between the

two groups revealed that the 3D planning group had a larger amount of correction in
EP

occlusal canting, frontal ramus inclination, and the distances from both L1 and
C

menton to the MSL. These variables are related to frontal symmetry, including the
AC

midline position, cheek symmetry, and dental canting. The results imply that the 2D

plan may be under-correcting or less accurate in patients with frontal asymmetry. The

reasons could be the difficulty in the accurate identification of the molar crown

position for occlusal canting on 2D radiographs, which can be readily identified using

15
 ACCEPTED MANUSCRIPT

a 3D model. Consequently, the under-correction of occlusal canting in the 2D system

can lead to the under-correction of the L1 and chin position because of the longer

radius from the rotation center. In addition, yaw rotation cannot be simulated in 2D

images, which may encounter bony collisions or gaps on the proximal segment

PT
affecting frontal ramus inclination. The results of the comparison between the 2D and

RI
3D plans in this study are in accordance with previous findings regarding the changes

SC
observed on transferring a 2D plan to a 3D simulation system.28

U
Consistency in the facial, maxillary, and mandibular midlines and chin position is
AN
the treatment goal of OGS. However, a mild degree of aberration occurs in individuals
M

and is accepted by the general population.37 Beyer et al.38 and Johnston et al.39 have

reported that the acceptance threshold of midline deviation for the general population
D
TE

is 2 mm; an occlusal cant in the frontal plane exceeding 4° was detected for the

recognition of occlusal canting by 90% of observers.40 Patients or nonprofessionals

EP

seem to be more tolerant to midline deviation than clinicians. In our study, the
C

distance from all final midsagittal landmarks (U1, L1, and Me) to the MSL was less
AC

than 2 mm, except for menton in the 2D planning group, which deviated by 2.5 mm

from the MSL. Moreover, the observed postoperative occlusal canting was less than

2° in both groups. Furthermore, soft tissue can sometimes cover the expression of

skeletal asymmetry clinically. This possibly explains why most patients in both

16
 ACCEPTED MANUSCRIPT

groups reported being satisfied with the surgical outcomes (80% vs. 90%) with no

patients reporting being unsatisfied, although the 3D planning group had superior

cephalometric measurements. Notably, more patients in the 3D planning group

reported being very satisfied with the surgical outcomes and facial appearance.

PT
In summary, this study compared the surgical outcomes of traditional 2D

RI
planning and post-simulation 3D planning. Quantitatively, the 3D plan provided more

SC
favorable overall results, particularly in the frontal measurement. This study does not

U
intend to overpower the well-established conventional 2D planning technique for
AN
OGS because most treatment outcomes of 2D planning were still satisfactory.
M

However, the results highlight the limitations of the 2D method and the possible

modifications in clinical planning and surgical execution. Surgeons should pay

D
TE

particular attention to the mandibular ramus area during fixation because this area is

less predictable or estimated by the traditional 2D planning. Moreover, this study

EP

shows that 3D planning with surgical simulation is a novel tool for preoperative
C

patient consultation and yields better symmetry correction.

AC

Acknowledgment

We thank Prof. Pei-Cheng Wang for his assistance with statistical analysis and Ms.

Lien-Shin Niu for her assistance with 3D simulation and production of positioning

17
 ACCEPTED MANUSCRIPT

guides. This study was supported by a grant from Chang Guan Memorial Hospital

(CMRPG3D1831)

Conflicts of interest

PT
None.

RI
Funding

SC
None

U
AN
Reference
1. Sabri R. Orthodontic objectives in orthognathic surgery: state of the art today.
M

World J Orthod 2006: 7: 177-91.

2. Athanasiou AE. Orthodontic Cephalometry,1995 Mosby-Wolfe, Times Mirror
D

International Publishers Limited1995.

3. Trpkova B, Prasad NG, Lam EW, et al. Assessment of facial asymmetries from
TE

posteroanterior cephalograms: validity of reference lines. Am J Orthod

Dentofacial Orthop 2003: 123: 512-20.
EP

4. Alexander Jacobson RLJ. Radiography Cephalometry from basics to 3-D imaging,

2nd edQuintessence Publishing Co,Inc 2006.
5. Troulis MJ, Everett P, Seldin EB, Kikinis R, Kaban LB. Development of a
C

three-dimensional treatment planning system based on computed tomographic

data. Int J Oral Maxillofac Surg 2002: 31: 349-57.
AC

6. Ellis E, 3rd. A method to passively align the sagittal ramus osteotomy segments. J
Oral Maxillofac Surg 2007: 65: 2125-30.
7. Swennen GR, Barth EL, Eulzer C, Schutyser F. The use of a new 3D splint and
double CT scan procedure to obtain an accurate anatomic virtual augmented
model of the skull. Int J Oral Maxillofac Surg 2007: 36: 146-52.
8. Xia JJ, Gateno J, Teichgraeber JF. New clinical protocol to evaluate
craniomaxillofacial deformity and plan surgical correction. J Oral Maxillofac Surg
2009: 67: 2093-106.

18
 ACCEPTED MANUSCRIPT
9. Swennen GR, Schutyser F. Three-dimensional cephalometry: spiral multi-slice vs
cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2006: 130:
410-6.
10. Xia JJ, Gateno J, Teichgraeber JF, et al. Accuracy of the computer-aided surgical
simulation (CASS) system in the treatment of patients with complex
craniomaxillofacial deformity: A pilot study. J Oral Maxillofac Surg 2007: 65:
248-54.

PT
11. Hsu SS, Gateno J, Bell RB, et al. Accuracy of a computer-aided surgical
simulation protocol for orthognathic surgery: a prospective multicenter study. J
Oral Maxillofac Surg 2013: 71: 128-42.

RI
12. Sun Y, Luebbers HT, Agbaje JO, et al. Accuracy of upper jaw positioning with
intermediate splint fabrication after virtual planning in bimaxillary orthognathic

SC
surgery. J Craniofac Surg 2013: 24: 1871-6.
13. Haas Jr OL, Becker OE, de Oliveira RB. Computer-aided planning in orthognathic
surgery-systematic review. Int J Oral Maxillofac Surg 2014.

U
14. Kawamata A, Ariji Y, Langlais RP. Three-dimensional computed tomography
AN
imaging in dentistry. Dent Clin North Am 2000: 44: 395-410.
15. Hwang HS, Hwang CH, Lee KH, Kang BC. Maxillofacial 3-dimensional image
analysis for the diagnosis of facial asymmetry. Am J Orthod Dentofacial Orthop
M

2006: 130: 779-85.

16. Kusnoto B. Two-dimensional cephalometry and computerized orthognathic
D

surgical treatment planning. Clin Plast Surg 2007: 34: 417-26.

17. van Vlijmen OJ, Maal TJ, Berge SJ, et al. A comparison between two-dimensional
TE

and three-dimensional cephalometry on frontal radiographs and on cone beam

computed tomography scans of human skulls. Eur J Oral Sci 2009: 117: 300-5.
EP

18. Yitschaky O, Redlich M, Abed Y, et al. Comparison of common hard tissue

cephalometric measurements between computed tomography 3D reconstruction
and conventional 2D cephalometric images. Angle Orthod 2011: 81: 11-16.
C

19. Aboul-Hosn Centenero S, Hernandez-Alfaro F. 3D planning in orthognathic

surgery: CAD/CAM surgical splints and prediction of the soft and hard tissues
AC

results - our experience in 16 cases. J Craniomaxillofac Surg 2012: 40: 162-8.

20. Lin HH, Chiang WC, Lo LJ, et al. Artifact-resistant superimposition of digital
dental models and cone-beam computed tomography images. J Oral Maxillofac
Surg 2013: 71: 1933-47.
21. BN. E. Modification in sagittal split osteotomy of the mandible. J Oral Surg
1977;35:157–159 1977.
22. Xia JJ, Shevchenko L, Gateno J, et al. Outcome study of computer-aided surgical
simulation in the treatment of patients with craniomaxillofacial deformities. J Oral

19
 ACCEPTED MANUSCRIPT
Maxillofac Surg 2011: 69: 2014-24.
23. Baker SB, Goldstein JA, Seruya M. Outcomes in computer-assisted surgical
simulation for orthognathic surgery. J Craniofac Surg 2012: 23: 509-13.
24. Lin HH, Chang HW, Lo LJ. Development of customized positioning guides using
computer-aided design and manufacturing technology for orthognathic surgery. Int
J Comput Assist Radiol Surg 2015: 10: 2021-33.
25. Lin HH, Lo LJ. Three-dimensional computer-assisted surgical simulation and

PT
intraoperative navigation in orthognathic surgery: a literature review. J Formos
Med Assoc 2015: 114: 300-7.
26. Badiali G, Roncari A, Bianchi A, et al. Navigation in Orthognathic Surgery: 3D

RI
Accuracy. Facial Plast Surg 2015: 31: 463-73.
27. Shirota T, Shiogama, S., Watanabe, H., Kurihara, Y. & Yamaguchi T.

SC
Three-dimensional virtual planning and intraoperative navigation for two-jaw
orthognathic surgery. J Oral Maxillofac Surg Med Pathol 2016.
28. Cheng-Ting Ho H-HL, Eric JW Liou, Lun-Jou Lo. Three-dimensional surgical

U
simulation improves the planning for correction of facial prognathism and
AN
asymmetry: A qualitative and quantitative study. Scientific Reports. Scientific
Reports 2017.
29. Burston CJ JR, Legan H, Murphy GA, Norton LA. Cephalometrics for
M

orthognathic surgery J Oral Surg 1979: 36:269–277.

30. Cheung LK, Chan YM, Jayaratne YS, Lo J. Three-dimensional cephalometric
D

norms of Chinese adults in Hong Kong with balanced facial profile. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2011: 112: e56-73.
TE

31. Bergeron L, Yu CC, Chen YR. Single-splint technique for correction of severe
facial asymmetry: correlation between intraoperative maxillomandibular complex
EP

roll and restoration of mouth symmetry. Plast Reconstr Surg 2008: 122: 1535-41.
32. Yu CC, Bergeron L, Lin CH, Chu YM, Chen YR. Single-splint technique in
orthognathic surgery: intraoperative checkpoints to control facial symmetry. Plast
C

Reconstr Surg 2009: 124: 879-86.

33. Patel PK, Novia MV. The surgical tools: the LeFort I, bilateral sagittal split
AC

osteotomy of the mandible, and the osseous genioplasty. Clin Plast Surg 2007: 34:
447-75.
34. Xia J. G, J. & Teichgraeber, F. Ch. 74, Computer-aided surgical simulation for
orthognathic surgery. In Current therapy in oral and maxillofacial surgery, (eds
Bell, R B et al) 2012: 604-12 (WB Saunder, 2012).
35. Griffitts TM. Computer Assisted Surgical Simulation Versus Model Surgery in
Orthognathic Surgery: A Postoperative Comparison of Surgical Outcomes. 95th
Annual Meeting, Scientific Sessions and Exhibition 2013.

20
 ACCEPTED MANUSCRIPT
36. Lin HH, Chang HW, Wang CH, Kim SG, Lo LJ. Three-dimensional
computer-assisted orthognathic surgery: experience of 37 patients. Ann Plast Surg
2015: 74 Suppl 2: S118-26.
37. Bishara SE, Burkey PS, Kharouf JG. Dental and facial asymmetries: a review.
Angle Orthod 1994: 64: 89-98.
38. Beyer JW, Lindauer SJ. Evaluation of dental midline position. Semin Orthod 1998:
4: 146-52.

PT
39. Johnston CD, Burden DJ, Stevenson MR. The influence of dental to facial midline
discrepancies on dental attractiveness ratings. Eur J Orthod 1999: 21: 517-22.
40. Padwa BL, Kaiser MO, Kaban LB. Occlusal cant in the frontal plane as a

RI
reflection of facial asymmetry. J Oral Maxillofac Surg 1997: 55: 811-6; discussion
17.

U SC
AN
M
D
TE
C EP
AC

21
 ACCEPTED MANUSCRIPT

Figure legend

Figure 1. Study flowchart

Figure 2. Landmark and reference lines on the lateral film for cephalometric

measurements

PT
Figure 3. Landmark and reference lines on the posterior–anterior film for

RI
cephalometric measurements

SC
Figure 4. Comparison of the extent of satisfaction following 2D and 3D surgical

U
plans
AN
Figure 5. A. Lateral and frontal views and cephalometrics (upper level) of a
M

24-year-old man before OGS. The patient had a concave profile, a reverse

incisor overjet, and facial asymmetry. B. His lateral and frontal views and
D
TE

cephalometrics (lower level) after surgery following the 2D plan. The

patient shows a straight profile, regular inter-incisor relationship and

EP

symmetrical face (the soft tissue covers the bony disparity on chin area).
C

Figure 6. A. Lateral and frontal views and cephalometrics (upper level) of a

AC

22-year-old woman before OGS. The patient had a concave profile, a

reverse incisor overjet, and facial asymmetry. B. Her lateral and frontal

views and cephalometrics (lower level) after the surgery following the 3D

plan. The patient shows a straight profile, normal inter-incisor relationship,

22
 ACCEPTED MANUSCRIPT

and symmetrical face (more balanced frontal ramus inclination and chin

position).

PT
RI
U SC
AN
M
D
TE
C EP
AC

23
 ACCEPTED MANUSCRIPT

Table 1 Definitions of cephalometric landmarks and reference lines

Landmark Abbreviation Definition

Crista galli Cg The geometric centre of the crista galli
Orbitale Or The most inferior point of infraorbital rim
Porion Po The highest points of the external acoustic meatus

Lateral-orbital LoR The intersection of the lateral orbital contour with the
LoL innominate line (PA view)

PT
Nasion N The middle point of the frontonasal suture
Anterior nasal spine ANS The most anterior midpoint of the anterior nasal spine of the
maxilla
Point A A The innermost point on the contour of the premaxilla

RI
between ANS and U1
Point B B The innermost point on the contour of the mandible between
bony chin and L1

SC
Upper incisor U1 Midpoint between the crowns of the maxillary central
incisors (PA)
Incisal edge of the maxillary central incisor (LA)
Lower incisor L1 Midpoint contact between the crowns of the mandibular
central incisors (PA)

U
Incisal edge of the mandibular central incisors (LA)
Pogonion Pog The most anterior midpoint of the chin on the outline of the
AN
mandibular symphysis
Menton Me The most inferior midpoint of the chin on the outline of the
mandibular symphysis.
Gonion Go The most everted point of the angle of the mandible
M

First maxillary molar U6L The midpoint of the left first maxillary molar (PA view)
U6R The midpoint of the right first maxillary molar
(PA view)
Condyle point CdL The most lateral point of left condyle head (PA view)
D

CdR The most lateral point of right condyle head (PA view)
Gonion GoL The most lateral point of left gonion (PA view)
TE

GoR The most lateral point of right gonion (PA view)

Soft tissue pogonion Pog’ Soft tissue over pogonion
Soft tissue menton Me’ Lowest point on soft tissue over mandible
Subnasale Sn In the midline, the junction where base of the columella of
the nose meets the upper lip
EP

Stomion superius Sts Highest midline point of upper lip

Stomion inferius Sti Highest midline point of lower lip
Labialis superior Ls Point denoting vermilion border of upper lip in midsagittal
plane
C

Labial inferior Li Point denoting vermilion border of lower lip in midsagittal

plane
AC

Pronasale Prn Soft tissue point on tip of nose

Glabella G’ Most prominent point in the median sagittal plane between
the supraorbital ridges
Orbital line A line connected LoL and LoR (PA view)
Ramus line A line connected Co and Go (PA view)
Mid-sagittal line MSL A line perpendicular to orbital line and across the mid-point
of the orbital line
Occlusal line A line connect U6L and U6R (PA view)
A line passing through one half of the cusp heights of the first
permanent molar and one half of the overbite of the incisors
(LA view)
Esthetic line E-line This line extends from the tip of soft tissue nose to soft tissue
pogonion

24
 ACCEPTED MANUSCRIPT

Table 2 Definitions of angular and linear measurements in cephalometric analysis

Angular measurement Definition

Hard tissue
SNA Angle between SN and NA line
SNB Angle between SN and NB line
ANB Angle between NA and AB line
SN-MP Angle between SN line and mandibular plane
OP-FH Angle between occlusal line and FH plane

PT
Angle convexity Angle between NA and AB line
Occlusal canting Angle between U6(R)-U6(L) and orbital line
U1-SN Angle between long axis of upper incisor and SN line
L1-MP Angle between long axis of lower incisor and mandibular plane

RI
Frontal ramus inclination Angle between ramus line (Co-Go) and orbital line
Difference of frontal ramus The absolute difference of angle between right frontal ramus

SC
inclination inclination and left frontal ramus inclination

Linear measurement Definition

U
Hard tissue
A-Nvert Distance form A point to perpendicular line from N point to FH
AN
plane
B-Nvert Distance from B point to perpendicular line from N point to FH
plane
U1-Nvert Distance from upper incisor edge to perpendicular line from N
M

point to FH plane
L1-Nvert Distance from lower incisor edge to perpendicular line from N
point to FH plane
D

Pg-Nvert Distance from Pogonoin to perpendicular line from N point to FH

plane
TE

U1-MSL Distance from midline of upper incisor to mid-sagittal line

L1-MSL Distance from midline of lower incisor to mid-sagittal line

EP

Me–MSL Distance from menton to mid-sagittal line

Overjet Distance from U1 to L1
Upper anterior facial
height to lower Ratio of the length of N-ANS and ANS-Me
C

anterior facial height

Soft tissue
AC

Facial convexity Angle from G’Sn’ and Sn’Pg’ line

Sn’-G’vert Distance from Sn’ point to perpendicular line from G’ point to FH
plane
Pg’-G’vert Distance from Pg’ point to perpendicular line from G’ point to FH
plane
Upper lip to E-line Distance from E-line to Ls point
Lower lip to E-line Distance from E-line to Li point
Upper lip length to Ratio of the length of Sn-Sto and Sto-Me’
lower lip length

25
 ACCEPTED MANUSCRIPT

Table 3 Preoperative (T1) and postoperative (T2) cephalometric measurements and comparison of treatment changes between the 2D and 3D

PT
planning groups

RI
2D 3D 2D T1 vs 3DT1 2D T2 vs 3DT2 2D (T2-T1) vs 3D (T2-T1)
Skeletal-sagittal T1 T2 T2-T1 p-value T1 T2 T2-T1 p-value p-value p-value p-value
SNA (°) 82.50 ± 4.06 84.64 ± 4.06 2.14 ± 1.84 .000* 81.68 ± 3.89 84.85 ± 3.63 2.96± 2.11 .000* .429 .994 .113

SC
SNB (°) 85.47 ± 4.37 81.42 ± 3.66 -4.05 ± 2.45 .000* 84.88 ± 4.16 81.47 ± 3.62 -3.41 ±1.90 .000* .599 .952 .952
ANB (°) -3.05 ±1.29 3.23 ± 2.24 6.28 ± 2.54 .000* -3.20 ± 2.48 3.28 ± 2.49 6.38 ± 2.31 .000* .770 .875 .874
SN-MP (°) 36.40 ± 4.61 41.15 ± 4.67 4.75± 3.23 .000* 34.98 ± 5.06 38.82 ± 4.87 3.83 ±2.77 .023* .261 .063 .250
OP-FH (°) 11.7 ± 3.76 15.95 ± 3.85 4.25± 2.96 .000* 10.47 ± 4.47 15.03 ± 4.05 4.55 ± 2.91 .000* .255 .369 .690

U
Angle convexity (°) -3.87 ± 5.15 4.73 ± 4.26 8.60 ± 5.14 .000* -5.13 ± 8.34 4.12 ± 5.92 9.25 ±5.69 .000* .482 .645 .644
Overjet (mm) -4.62 ± 2.18 1.75±0.85 6.23±1.92 .000* -4.50 ± 3.95 1.77±0.43 6.27±3.91 .000* .888 .924 .905

AN
A-Nv (mm) -1.07 ± 2.71 1.15 ± 3.47 2.22 ± 2.33 .000* -1.98 ± 3.78 1.24 ± 3.87 3.15 ± 2.90 .000* .285 .986 .175
B-Nv (mm) 3.85 ± 4.61 -2.70 ± 6.19 -6.55 ± 4.23 .000* 3.18 ± 6.68 -4.20± 5.71 -7.38 ±4.28 .000* .654 .333 .450
Pg-Nv (mm) 4.73 ± 7.10 -1.73 ± 6.25 -6.46 ± 4.92 .000* 4.13 ± 6.88 -3.92 ±7.24 -8.05 ±5.04 .000* .740 .214 .220
NANS:ANS-Me 0.80 ± 0.06 0.82±0.06 0.00±0.06 .084 0.82 ± 0.08 0.86±0.11 0.04±0.08 .018* .179 .062 .060

M
Dental
UI-SN (°) 110.77±9.99 105.60±8.7 -5.17 ± 4.75 .000* 111.93±7.20 105.97 ± 5.08 -5.97 ±3.93 .000* .606 .835 .480
L1-MP (°) 84.70 ± 4.41 84.25 ± 4.08 -0.45 ± 0.75 .003* 86.60 ± 4.53 86.43 ± 4.45 -0.17 ± 0.38 .000* .105 .052 .068
U1-Nv (mm) 6.95 ± 5.40 4.72 ± 4.56 -2.23 ±2.12 .000* 6.68 ± 5.68 3.93 ± 4.42 -2.75 ± 2.15 .000* .853 .501 .353

D
L1-Nv (mm) 8.92 ± 5.45 3.22 ± 4.99 -5.70 ± 3.16 .000* 8.05 ± 5.94 1.62 ± 4.69 -6.43 ± 3.27 .000* .558 .205 .381
Frontal view

TE
Occlusal canting (°) 2.32 ±1.13 1.48± 0.96 -0.83 ± 0.87 .000* 2.22 ± 2.13 0.62 ± 0.76 -1.60 ± 1.81 .000* .255 .000* .041*
Ramus inclination 4.93 ± 1.87 2.97 ± 1.05 -1.97 ± 1.29 .000* 4.80 ± 2.76 1.72 ± 1.42 -3.08 ± 2.23 .000* .827 .000* .020*
difference (°)
U1-MSL (mm) 1.80 ± 1.36 0.55 ± 0.80 1.52 ± 1.15 .000* 1.52 ± 1.15 0.35 ± 0.46 0.35 ± 0.46 .000* .387 .240 .240
EP
L1-MSL (mm) 3.78 ±2.12 1.95 ± 1.08 3.42 ± 1.80 .000* 3.42 ± 1.80 0.55 ± 0.67 0.55 ± 0.67 .000* .473 .000* .000*
Me-MSL (mm) 5.61 ± 1.89 2.50 ± 1.04 5.33 ± 2.53 .000* 5.33 ± 2.53 1.20 ± 1.25 1.20 ± 1.25 .000* .624 .000* .000*
Soft tissue
Upper lip to Lower 0.48 ± 0.06 0.52±0.06 0.04±0.07 .003* 0.50 ± 0.10 0.55±0.14 0.09±0.08 .000* .232 .007* .010*
C

lip
Upper lip to E-line -2.82 ± 1.69 0.07±1.87 2.88±2.48 .000* 0.93 ± 1.57 0.47±0.86 2.97±2.33 .000* .146 .057 .893
AC

Lower lip to E-line 1.10 ±2.57 3.47±3.16 2.37±2.40 .000* 1.03 ± 1.97 3.25±2.84 2.22±2.36 .000* .910 .780 .807
Facial convexity (°) 0.88 ± 4.40 9.36 ± 5.24 8.48 ±6.17 .000* 0.98 ± 7.28 9.49 ± 5.90 8.51 ± 5.12 .000* .952 .932 .983
Sn’-G’vert (mm) 2.97 ± 3.41 7.48 ± 4.31 4.52± 2.93 .000* 2.98 ± 3.75 6.42 ± 3.23 3.44 ± 1.76 .000* .989 .283 .089
Pg’-G’vert (mm) 6.87 ± 6.41 0.85 ± 6.24 -6.02 ±4.79 .000* 6.85 ± 5.34 1.13 ± 3.69 -5.72 ± 3.84 .000* .991 .831 .790
Data are presented as mean ± standard deviation.

26
 ACCEPTED MANUSCRIPT

Table 4 Comparison of perceptions of postoperative improvements in the 2D and

3D planning groups

2D (N=30) 3D (N=30) p value

Very satisfied 6 14 .028*

PT
Satisfied 18 13 .196

RI
(Very satisfied + Satisfied) 24 27 .278

SC
Acceptable 6 3 .278

*p < 0.05.

U
AN
M
D
TE
C EP
AC

27
 ACCEPTED MANUSCRIPT

Table 1 Definitions of cephalometric landmarks and reference lines

Landmark Abbreviation Definition

Crista galli Cg The geometric centre of the crista galli
Orbitale Or The most inferior point of infraorbital rim
Porion Po The highest points of the external acoustic meatus

Lateral-orbital LoR The intersection of the lateral orbital contour with the
LoL innominate line (PA view)

PT
Nasion N The middle point of the frontonasal suture
Anterior nasal spine ANS The most anterior midpoint of the anterior nasal spine of the
maxilla
Point A A The innermost point on the contour of the premaxilla

RI
between ANS and U1
Point B B The innermost point on the contour of the mandible between
bony chin and L1

SC
Upper incisor U1 Midpoint between the crowns of the maxillary central
incisors (PA)
Incisal edge of the maxillary central incisor (LA)
Lower incisor L1 Midpoint contact between the crowns of the mandibular
central incisors (PA)

U
Incisal edge of the mandibular central incisors (LA)
Pogonion Pog The most anterior midpoint of the chin on the outline of the
AN
mandibular symphysis
Menton Me The most inferior midpoint of the chin on the outline of the
mandibular symphysis.
Gonion Go The most everted point of the angle of the mandible
M

First maxillary molar U6L The midpoint of the left first maxillary molar (PA view)
U6R The midpoint of the right first maxillary molar
(PA view)
Condyle point CdL The most lateral point of left condyle head (PA view)
D

CdR The most lateral point of right condyle head (PA view)
Gonion GoL The most lateral point of left gonion (PA view)
TE

GoR The most lateral point of right gonion (PA view)

Soft tissue pogonion Pog’ Soft tissue over pogonion
Soft tissue menton Me’ Lowest point on soft tissue over mandible
Subnasale Sn In the midline, the junction where base of the columella of
the nose meets the upper lip
EP

Stomion superius Sts Highest midline point of upper lip

Stomion inferius Sti Highest midline point of lower lip
Labialis superior Ls Point denoting vermilion border of upper lip in midsagittal
plane
C

Labial inferior Li Point denoting vermilion border of lower lip in midsagittal

plane
AC

Pronasale Prn Soft tissue point on tip of nose

Glabella G’ Most prominent point in the median sagittal plane between
the supraorbital ridges
Orbital line A line connected LoL and LoR (PA view)
Ramus line A line connected Co and Go (PA view)
Mid-sagittal line MSL A line perpendicular to orbital line and across the mid-point
of the orbital line
Occlusal line A line connect U6L and U6R (PA view)
A line passing through one half of the cusp heights of the first
permanent molar and one half of the overbite of the incisors
(LA view)
Esthetic line E-line This line extends from the tip of soft tissue nose to soft tissue
pogonion
 ACCEPTED MANUSCRIPT

Table 2 Definitions of angular and linear measurements in cephalometric analysis

Angular measurement Definition

Hard tissue
SNA Angle between SN and NA line
SNB Angle between SN and NB line
ANB Angle between NA and AB line
SN-MP Angle between SN line and mandibular plane
OP-FH Angle between occlusal line and FH plane

PT
Angle convexity Angle between NA and AB line
Occlusal canting Angle between U6(R)-U6(L) and orbital line
U1-SN Angle between long axis of upper incisor and SN line
L1-MP Angle between long axis of lower incisor and mandibular plane

RI
Frontal ramus inclination Angle between ramus line (Co-Go) and orbital line
Difference of frontal ramus The absolute difference of angle between right frontal ramus

SC
inclination inclination and left frontal ramus inclination

Linear measurement Definition

U
Hard tissue
A-Nvert Distance form A point to perpendicular line from N point to FH
AN
plane
B-Nvert Distance from B point to perpendicular line from N point to FH
plane
U1-Nvert Distance from upper incisor edge to perpendicular line from N
M

point to FH plane
L1-Nvert Distance from lower incisor edge to perpendicular line from N
point to FH plane
D

Pg-Nvert Distance from Pogonoin to perpendicular line from N point to FH

plane
TE

U1-MSL Distance from midline of upper incisor to mid-sagittal line

L1-MSL Distance from midline of lower incisor to mid-sagittal line

EP

Me–MSL Distance from menton to mid-sagittal line

Overjet Distance from U1 to L1
Upper anterior facial
height to lower Ratio of the length of N-ANS and ANS-Me
C

anterior facial height

Soft tissue
AC

Facial convexity Angle from G’Sn’ and Sn’Pg’ line

Sn’-G’vert Distance from Sn’ point to perpendicular line from G’ point to FH
plane
Pg’-G’vert Distance from Pg’ point to perpendicular line from G’ point to FH
plane
Upper lip to E-line Distance from E-line to Ls point
Lower lip to E-line Distance from E-line to Li point
Upper lip length to Ratio of the length of Sn-Sto and Sto-Me’
lower lip length

1
 ACCEPTED MANUSCRIPT

Table 3 Preoperative (T1) and postoperative (T2) cephalometric measurements and comparison of treatment changes between the 2D and 3D

PT
planning groups

RI
2D 3D 2D T1 vs 3DT1 2D T2 vs 3DT2 2D (T2-T1) vs 3D (T2-T1)
Skeletal-sagittal T1 T2 T2-T1 p-value T1 T2 T2-T1 p-value p-value p-value p-value
SNA (°) 82.50 ± 4.06 84.64 ± 4.06 2.14 ± 1.84 .000* 81.68 ± 3.89 84.85 ± 3.63 2.96± 2.11 .000* .429 .994 .113

SC
SNB (°) 85.47 ± 4.37 81.42 ± 3.66 -4.05 ± 2.45 .000* 84.88 ± 4.16 81.47 ± 3.62 -3.41 ±1.90 .000* .599 .952 .952
ANB (°) -3.05 ±1.29 3.23 ± 2.24 6.28 ± 2.54 .000* -3.20 ± 2.48 3.28 ± 2.49 6.38 ± 2.31 .000* .770 .875 .874
SN-MP (°) 36.40 ± 4.61 41.15 ± 4.67 4.75± 3.23 .000* 34.98 ± 5.06 38.82 ± 4.87 3.83 ±2.77 .023* .261 .063 .250
OP-FH (°) 11.7 ± 3.76 15.95 ± 3.85 4.25± 2.96 .000* 10.47 ± 4.47 15.03 ± 4.05 4.55 ± 2.91 .000* .255 .369 .690

U
Angle convexity (°) -3.87 ± 5.15 4.73 ± 4.26 8.60 ± 5.14 .000* -5.13 ± 8.34 4.12 ± 5.92 9.25 ±5.69 .000* .482 .645 .644
Overjet (mm) -4.62 ± 2.18 1.75±0.85 6.23±1.92 .000* -4.50 ± 3.95 1.77±0.43 6.27±3.91 .000* .888 .924 .905

AN
A-Nv (mm) -1.07 ± 2.71 1.15 ± 3.47 2.22 ± 2.33 .000* -1.98 ± 3.78 1.24 ± 3.87 3.15 ± 2.90 .000* .285 .986 .175
B-Nv (mm) 3.85 ± 4.61 -2.70 ± 6.19 -6.55 ± 4.23 .000* 3.18 ± 6.68 -4.20± 5.71 -7.38 ±4.28 .000* .654 .333 .450
Pg-Nv (mm) 4.73 ± 7.10 -1.73 ± 6.25 -6.46 ± 4.92 .000* 4.13 ± 6.88 -3.92 ±7.24 -8.05 ±5.04 .000* .740 .214 .220
NANS:ANS-Me 0.80 ± 0.06 0.82±0.06 0.00±0.06 .084 0.82 ± 0.08 0.86±0.11 0.04±0.08 .018* .179 .062 .060

M
Dental
UI-SN (°) 110.77±9.99 105.60±8.7 -5.17 ± 4.75 .000* 111.93±7.20 105.97 ± 5.08 -5.97 ±3.93 .000* .606 .835 .480
L1-MP (°) 84.70 ± 4.41 84.25 ± 4.08 -0.45 ± 0.75 .003* 86.60 ± 4.53 86.43 ± 4.45 -0.17 ± 0.38 .000* .105 .052 .068
U1-Nv (mm) 6.95 ± 5.40 4.72 ± 4.56 -2.23 ±2.12 .000* 6.68 ± 5.68 3.93 ± 4.42 -2.75 ± 2.15 .000* .853 .501 .353

D
L1-Nv (mm) 8.92 ± 5.45 3.22 ± 4.99 -5.70 ± 3.16 .000* 8.05 ± 5.94 1.62 ± 4.69 -6.43 ± 3.27 .000* .558 .205 .381
Frontal view

TE
Occlusal canting (°) 2.32 ±1.13 1.48± 0.96 -0.83 ± 0.87 .000* 2.22 ± 2.13 0.62 ± 0.76 -1.60 ± 1.81 .000* .255 .000* .041*
Ramus inclination 4.93 ± 1.87 2.97 ± 1.05 -1.97 ± 1.29 .000* 4.80 ± 2.76 1.72 ± 1.42 -3.08 ± 2.23 .000* .827 .000* .020*
difference (°)
U1-MSL (mm) 1.80 ± 1.36 0.55 ± 0.80 1.52 ± 1.15 .000* 1.52 ± 1.15 0.35 ± 0.46 0.35 ± 0.46 .000* .387 .240 .240
EP
L1-MSL (mm) 3.78 ±2.12 1.95 ± 1.08 3.42 ± 1.80 .000* 3.42 ± 1.80 0.55 ± 0.67 0.55 ± 0.67 .000* .473 .000* .000*
Me-MSL (mm) 5.61 ± 1.89 2.50 ± 1.04 5.33 ± 2.53 .000* 5.33 ± 2.53 1.20 ± 1.25 1.20 ± 1.25 .000* .624 .000* .000*
Soft tissue
Upper lip to Lower 0.48 ± 0.06 0.52±0.06 0.04±0.07 .003* 0.50 ± 0.10 0.55±0.14 0.09±0.08 .000* .232 .007* .010*
C

lip
Upper lip to E-line -2.82 ± 1.69 0.07±1.87 2.88±2.48 .000* 0.93 ± 1.57 0.47±0.86 2.97±2.33 .000* .146 .057 .893
AC

Lower lip to E-line 1.10 ±2.57 3.47±3.16 2.37±2.40 .000* 1.03 ± 1.97 3.25±2.84 2.22±2.36 .000* .910 .780 .807
Facial convexity (°) 0.88 ± 4.40 9.36 ± 5.24 8.48 ±6.17 .000* 0.98 ± 7.28 9.49 ± 5.90 8.51 ± 5.12 .000* .952 .932 .983
Sn’-G’vert (mm) 2.97 ± 3.41 7.48 ± 4.31 4.52± 2.93 .000* 2.98 ± 3.75 6.42 ± 3.23 3.44 ± 1.76 .000* .989 .283 .089
Pg’-G’vert (mm) 6.87 ± 6.41 0.85 ± 6.24 -6.02 ±4.79 .000* 6.85 ± 5.34 1.13 ± 3.69 -5.72 ± 3.84 .000* .991 .831 .790

1
 ACCEPTED MANUSCRIPT

Table 4 Comparison of perceptions of postoperative improvements in the 2D and

3D planning groups

2D (N=30) 3D (N=30) p value

Very satisfied 6 14 .028*

PT
Satisfied 18 13 .196

RI
(Very satisfied + Satisfied) 24 27 .278

SC
Acceptable 6 3 .278

*p < 0.05.

U
AN
M
D
TE
C EP
AC

1
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC