Journal of Cranio-Maxillo-Facial Surgery 50 (2022) 353e363

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Journal of Cranio-Maxillo-Facial Surgery

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A three-dimensional cephalometric analysis of Japanese adults and its

usefulness in orthognathic surgery: A retrospective study
Hiroshi Yoshikawa a, Chihiro Tanikawa a, b, *, Shinsuke Ito a, Yosuke Tsukiboshi a,
Hitomi Ishii c, Ryuzo Kanomi c, Takashi Yamashiro a
a
Graduate School of Dentistry, Osaka University, Suita, Osaka, 5650871, Japan
b
Center for Advanced Medical Engineering and Informatics, Osaka University, Suita, Osaka, 5650871, Japan
c
Kanomi Orthodontic Office, Himeji-City, Japan

a r t i c l e i n f o a b s t r a c t

Article history: This study aimed to establish a three-dimensional (3D) cephalometric analysis of craniofacial
Paper received 4 December 2020 morphology and discuss its theoretical usefulness in orthognathic patients.
Received in revised form Cone-beam computed tomography (CBCT) images of Japanese subjects with skeletal Class I malocclu-
4 February 2022
sion before treatment were selected from among 1000 patients so that samples matched a historic 2D
Accepted 10 February 2022
Available online 18 February 2022
cephalometric cohort with normal occlusion using propensity score matching. In each CBCT image, 67 3D
measurements were calculated based on manually identified landmarks. The mean and standard deviation
of the measurements were calculated and used as the normative range for each sex. To confirm the use-
Keywords:
Three-dimensional (3D)
fulness of the 3D measurements, pre- and post-treatment CT data of nine jaw deformity patients who
Two-dimensional (2D) underwent orthognathic surgery with two-dimensional planning (2DP) in the past were used. Pre- and
Cephalometry post-treatment CT values were evaluated with a paired t-test as well as a Z-score, which was calculated
Malocclusion using the aforementioned normative range, and then categorized into five groups (“deteriorated”, “no
Mandible improvement”, “over-treatment”, “no change”, “improvement”) with
1 < Z-score < 1 considered normal.
Maxilla Fifty-six patients were matched to normal skeletal 1 subjects. The normative range of 67 items
Orthognathic surgery indicating 3D craniofacial morphology of the Japanese was calculated. Postoperatively, the horizontal
position of the pogonion to the mid-sagittal plane significantly decreased (p ¼ 0.043) and “improved”;
however, the ramus axis on the right side significantly increased (p ¼ 0.005) and “deteriorated”.
Maxillary yaw and the horizontal position of the gonion also tended to “deteriorated”.
The normative range for the 3D cephalometric analysis in Japanese has been established. Given
findings of deteriorated maxillomandibular yawing after surgery when using conventional 2DP, 3D
cephalometric measurements should be used when planning jaw positions after surgery for orthognathic
patients.
© 2022 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction merits in terms of accuracy, stability, operation time, and other

With recent technological advancements, three-dimensional
treatment planning (3DP) has become available as an alternative
to conventional two-dimensional treatment planning (2DP) for
orthognathic surgery. In recent years, various methods using 3DP
have been developed, and 3DP has been reported to show some
* Corresponding author. Graduate School of Dentistry, Osaka University, Suita,
Osaka, 5650871, Japan.
E-mail addresses: ctanika@dent.osaka-u.ac.jp, ctanika@gmail.com (C. Tanikawa).
features (Da Ferraz et al., 2021; Monteiro Carneiro et al., 2020;
Nilsson et al., 2020; Stokbro et al., 2019). In conventional 2DP,
surgery is planned based on the analysis of a 2D cephalogram,
conventional facial and oral photographs, and articulator models
(Kusnoto, 2007). Substantial research has been conducted since the
late 20th century on 2D cephalograms, and the normative range of
2D skeletal morphology has been reported from various perspec-
tives (Downs, 1948; Ricketts, 1969; Tweed, 1969) While 2DP re-
mains the most popular method for planning orthognathic surgery
in the clinical setting, it is associated with three main limitations.
First, 2DP does not always accurately reflect the 3D morphology,

https://doi.org/10.1016/j.jcms.2022.02.002
1010-5182/© 2022 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

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H. Yoshikawa, C. Tanikawa, S. Ito et al.
position, or size of the maxilla and mandible (Gateno et al., 2011a).
Second, 2D cephalometric projection images contain distortion,
especially in cases with facial asymmetry (Gateno et al., 2011b).
Third, several sources of errors in the face bow transfer of the
models, including mounting errors, swelling of mounting stones,
and metallic deformations of the face bow and articulators, should
be considered (Zizelmann et al., 2012).
In this context, several reports have outlined the usefulness of
3D evaluation and 3DP. A previous study reported that among cases
in which 2DP was performed (n ¼ 30), 83.3% of the cases were
found to require at least one modification when a 3D evaluation
was added (Lonic et al., 2016). Another study showed that soft-
tissue asymmetry was significantly reduced following surgery
with 3DP, although no significant differences were observed in the
preoperative and postoperative soft tissue parameters obtained
during conventional 2DP. In one study that compared the maxil-
lofacial morphology between patients who underwent surgery
following 2DP (n ¼ 18) and 3DP (n ¼ 19), only the 3DP group
showed significant changes in the horizontal symmetry of the
gonion and the yaw of the occlusal plane, differing significantly
from the 2DP group (Udomlarptham et al., 2018). Symmetry is an
important treatment goal; however, treatment results should also
be compared to the normative range of 3D variables. Thus far, no
reports have examined whether 3D variables are within the
normative range after surgery. Prior to the introduction of the 3DP
system, it will be necessary to establish the normative ranges of
variables assessed in the 3D analysis of craniofacial morphology.
Thus, the present study aimed to establish a three-dimensional
(3D) “cephalometric” analysis of craniofacial morphology based on
the normative range, and discuss its theoretical usefulness in
orthognathic patients.
2. Materials and methods
2.1. Samples
Ethical approval for this study was obtained from the Institu-
tional Review Board of Osaka University Dental Hospital (No. H30-
E5-1). The requirement for informed consent was waived due to the
retrospective nature of the study. This retrospective study included
1000 patients who underwent cone-beam computed tomography
(CBCT) with centric occlusion in private orthodontic clinics. CBCT
images of subjects with skeletal Class I malocclusion before treat-
ment were selected from among 1000 patients so that samples
matched a historic 2D cephalometric cohort with normal occlusion
(Wada, 1977) using propensity score matching. Propensity score
matching was conducted according to the A pointenasioneB point
angle (ANB) and Frankfort mandibular plane angle (FMA) measured
using lateral cephalograms generated from CBCT images. The
required sample size was calculated based on the sampling size of
the population mean. A sample size achieved a 0.5 margin of error
with a 99% confidence interval, assuming that the population
standard deviation of the ANB was 1.0 . The inclusion criteria were
as follows: 17e40 years of age, skeletal Class 1 malocclusion, and a
history of diagnostic CBCT for nonroutine orthodontic treatment (to
minimize radiation exposure, scans were only performed when the
diagnostic benefits outweighed the risks associated with radiation
exposure). The exclusion criteria were as follows: a history of or-
thodontic treatment, craniofacial or growth abnormalities, and
systemic disease or temporomandibular joint disorder. The CBCT
examinations were performed with a CBCT scanner in low-dose
mode (Alphard-3030; Asahi Roentgen Ind. Co., Ltd., Kyoto, Japan).
354
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Journal of Cranio-Maxillo-Facial Surgery 50 (2022) 353e363
CBCT images were taken at 80 kV and 2 mA. Axial images were
obtained with the X-ray beam parallel to the Frankfort plane. The
field of view was 20  20 cm, and the voxel size was
0.39  0.39  0.39 mm. The voxels were exported in the Digital
Imaging and Communications in Medicine (DICOM) format.
2.2. Segmentation
3D reconstructions of the cranium and mandible were created
using a 3D image processing software program (Mimics, Materi-
alise NV, Leuven, Belgium). The program stores slices captured by
CBCT scanners as DICOM images, and generates virtual 3D models
corresponding to body parts and exports them as surface STL files.
2.3. Landmark identification and coordinate system
The 3D data were displayed on a 17-inch LCD monitor (1701FP;
Dell Inc., Round Rock, TX, USA). Using a craniofacial surgery plan-
ning software program (ProPlan, Materialise NV, Leuven, Belgium),
27 cranial and 28 mandibular landmarks were plotted on the 3D
data. The positions of the landmarks, based on previous de-
scriptions (Figs. 1 and 2 and Tables 1 and 2), were identified from a
visual inspection of images and digitized using a computer mouse
cursor. A reliability test for identifying the landmarks was per-
formed as described in the supplementary files. In short, all land-
marks satisfied absolute distance between two sessions <2 mm
with “very good” reliability (intraclass correlation coefficients of
0.9) (Tsukiboshi et al., 2020). Axial determination of the head was
performed based on the Frankfort horizontal (FH) plane, with the
nasion as the origin (Fig. 3).
2.4. Calculation of normative ranges in the Japanese population by
3D cephalometric analysis
Sixty-one measurement items (distances and angles) were
selected and calculated by referring to a report on 2D and 3D
cephalometry (Alcalde et al., 1998; Engel and Spolter, 1981; Ioi et al.,
2007; Miyajima et al., 1996; Storniolo-Souza et al., 2021; Uesato
et al., 1978; Wada, 1977). In addition, the condylar axis of the
condylar head on the both sides, the angle between the mandibular
ramus and the mid-sagittal plane (MSP) (ramus axis) on the both
sides, the cant of the left and right gonions (Go cant), and the yaw of
the maxilla were newly set as measurement items. That is, a total of
67 3D measurements were calculated based on the manually
identified landmarks. The normative range (mean ± 1 standard
deviation) of each measurement item was calculated for each sex.
2.5. Statistical analyses
Independent Student's t-tests were applied to each parameter to
examine the differences between males and females and between
present and conventional studies. p values were adjusted using the
Benjamini-Hochberg false discovery rate control procedure. A p-
value of 0.05 was considered statistically significant.
2.6. Evaluation before and after orthognathic surgery
Nine patients with jaw deformities (Skeletal Class 2 [Sk2 sub-
group, n ¼ 3, cases 1e3], Class 3 [Sk3 subgroup, n ¼ 3, cases 4e6],
right deviation of the mandible [Dev subgroup, n ¼ 3, cases 7e9]; in
all cases, Le Fort I osteotomy and SSRO with rigid screw fixation was
performed), who had undergone orthognathic surgery at Osaka
H. Yoshikawa, C. Tanikawa, S. Ito et al. Journal of Cranio-Maxillo-Facial Surgery 50 (2022) 353e363

Fig. 1. Landmarks of the cranial bone. The landmarks of the cranial bone used in the present study. Definitions of the landmarks are listed in Table 2. (a) Sagittal view through the
center of the sella turcica. Point 1 (sella) was set on this plane. (b) Frontal view. (c) Right-side view. (d) Inferior view. (e) Left-side view.

Fig. 2. Landmarks of the mandible The landmarks of the mandible used in the present study. Definitions of the landmarks are listed in Table 3. (a) Inferior view. (b) Frontal view. (c)
Right-side view. (d) Superior view. (e) Left-side view.

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H. Yoshikawa, C. Tanikawa, S. Ito et al. Journal of Cranio-Maxillo-Facial Surgery 50 (2022) 353e363

Table 1
Definitions and abbreviations of the cranial landmarks.

Landmark Abbreviation Definition

1 Sella S The central point of the sella turcica

2 Sella turcica posterior Sp The midpoint of the posterior clinoid process
3 Nasion N The midpoint of the frontonasal suture
4 Anterior nasal spine ANS The most anterior midpoint of the anterior nasal spine of the maxilla
5 A-Point A The point of maximum concavity in the midline of the alveolar process of the maxilla
6 Right orbitale OrL The most inferior point of the right infraorbital rim
7 Left orbitale OrR The most inferior point of the left infraorbital rim
8 Left aperture NL The most lateral point of the piriform aperture
9 Right aperture NR The most lateral point of the piriform aperture
10 Right frontozygomatic AZ The most medial and anterior point of the right frontozygomatic suture at the lateral orbital rim
11 Right jugale JR The most concave point between the lateral margin of the upper zygomatic bone and the
upper margin of the zygomatic arch
12 Right porion PoR The most superior point of the right external acoustic meatus
13 Left frontozygomatic ZA The most medial and anterior point of the left frontozygomatic suture at the lateral orbital rim
14 Left jugale JL The most concave point between the lateral margin of the upper zygomatic bone and the
upper margin of the zygomatic arch
15 Left porion PoL The most superior point of the left external acoustic meatus
16 Posterior nasal spine PNS The most posterior midpoint of the posterior nasal spine of the palatine bone
17 Basion Ba The most anterior point of the foramen magnum
18 Right mastoid process MPR The most inferior point of the right mastoid process
19 Left mastoid process MPL The most inferior point of the left mastoid process
20 Incisal tip of right upper central incisor IsU1R The midpoint of the incisal edge of the upper right central incisor
21 Apex of right upper central incisor ApU1R The apex of the upper right central incisor
22 Incisal tip of left upper central incisor IsU1L The mesiodistal midpoint of the incisal edge of the upper left central incisor
23 Apex of left upper central incisor ApU1L The apex of the upper left central incisor
24 Upper right first molar UR6 The mesiobuccal cusp tip of the upper right first molar
25 Upper left first molar UL6 The mesiobuccal cusp tip of the upper left first molar
26 Incisal tip of upper central incisors IsU1 The midpoint of IsU1R and IsU1L
27 Apex of upper central incisors ApU1 The midpoint of ApU1R and ApU1L

Table 2
Definitions and abbreviations of the mandibular landmarks.

Landmark Abbreviation Definition

1 Pogonion Pog The most anterior midpoint of the chin on the outline of the mandibular symphysis
2 Gnathion Gn The contour of the bony chin
3 Menton Me The most inferior midpoint of the chin on the outline of the mandibular symphysis
4 B-Point B The point of maximum concavity in the midline of the alveolar process of the mandible
5 Left condyle CoL The most superior point of the mandibular condyle (left)
6 Left medial point of the condyle Med. CoL The most medial point of the glenoid process of the mandible (left)
7 Left lateral point of the condyle Lat. CoL The most lateral point of the glenoid process of the mandible (left)
8 Left superior point of the condyle CoR The most superior point of the mandibular condyle (right)
9 Right medial point of the condyle Med. CoR The most lateral point of the glenoid process of the mandible (right)
10 Right lateral point of the condyle Lat. CoR The most lateral point of the glenoid process of the mandible (right)
11 Right superior point of the condyle GoL The point at each mandibular angle that is defined by dropping a perpendicular from
the intersection point of the tangent lines to the posterior margin of the mandibular
vertical ramus and inferior margin of the mandibular body or horizontal ramus (left)
12 Left inferior gonion Inf. Go L The contact point of the mandibular plane on the inferior margin of the mandibular ramus (left)
13 Left antegonial notch ImL The deepest point of the antegonial notch (left)
14 Left posterior gonion Pos. Go L The contact point of the ramus plane on the postero-inferior margin of the mandibular ramus (left)
15 Right gonion GoR The point at each mandibular angle that is defined by dropping a perpendicular from the
intersection point of the tangent lines to the posterior margin of the mandibular vertical ramus
and inferior margin of the mandibular body or horizontal ramus (right)
16 Right inferior gonion Inf. Go R The contact point of the mandibular plane on the inferior margin of the mandibular ramus (right)
17 Right antegonial notch ImR The deepest point of the antegonial notch (right)
18 Right posterior gonion Pos. Go R The contact point of the ramus plane on the postero-inferior margin of the mandibular ramus (right)
19 Incisal tip of right lower central incisor IsL1R The mesiodistal middle point of the incisal edge of the lower right central incisor
20 Apex of right lower central incisor ApL1R The apex of the lower right central incisor
21 Incisal tip of left lower central incisor IsL1L The mesiodistal middle point of the incisal edge of the lower left central incisor
22 Apex of left lower central incisor ApL1L The apex of the lower left central incisor
23 Apex of lower central incisors ApL1 The midpoint of ApL1R and ApL1L
24 Incisal tip of lower central incisors IsL1 The midpoint of IsL1R and IsL1L
25 The buccal surface of the lower right first molar B6R The buccal groove of the lower right first molar
26 Lower right first molar MoR The distobuccal cusp of the lower right first molar
27 The buccal surface of the lower left first molar B6L The buccal groove of the lower left first molar
28 Lower left first molar MoL The distobuccal cusp of the lower left first molar

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Table 4
Propensity score matching data in male and female patients. A total of 56 images
(male, n ¼ 28; female, n ¼ 28) extracted from 1000 Japanese adult CBCT images with
ANB and FMA were matched to a historic cohort described in a previous report
(Wada, 1977).

Male (n ¼ 28) Female (n ¼ 28)

 
ANB ( ) FMA ( ) ANB ( ) FMA ( )

Present study Average 3.04 29.07 3.14 29.54

SD 1.36 5.76 1.25 5.06
Minimum 1.68 23.31 1.89 24.49
Maximum 4.39 34.84 4.39 34.60
Wada (1977). Average 3.20 28.00 2.80 30.50
SD 2.38 6.08 2.44 3.60

ANB, A pointenasioneB point angle; FMA, Frankfort mandibular plane angle; SD,
standard deviation.

For each measurement item, the Z-score was also calculated as

Fig. 3. Axial measurement of the head The Frankfort horizontal (FH) plane was defined
as a plane passing through the left and right porions and the midpoint between the left
and right orbitale. The nasion was defined as the origin of the cranial and mandibular
surfaces, and the plane parallel to the FH plane was defined as the XZ plane. The YZ
plane (mid-sagittal plane; MSP) was defined as a plane passing through the nasion and
basion, and perpendicular to the FH plane. The XY plane (axial plane) was defined as a
plane passing through the nasion and perpendicular to the XZ and YZ planes.
Abbreviations: N, nasion; OrR, right orbitale; OrL, left orbitale; PoL, left porion.
follows:
Z-score ¼ [(measured value) - average]/normative range.
The preoperative and postoperative Z-scores were defined as
Zpre and Zpost, respectively. In only the 14 selected items, including
basic measurement items and new items for detecting the direction
or inclination of the mandibular ramus and the yawing of the
maxilla, the Zpre and Zpost values were compared and classified into
five newly established categories. Items that improved were classi-
fied as “Improved,” items that improved beyond the normative range
were defined as “Over-treated,” and items that worsened were
defined as “Deteriorated.” When all three cases were classified
separately, “No Change” was assigned if the preoperative range was
within the normative range, and “No Improvement” was assigned if
it was outside the normative range (Table 3).

University Dental Hospital were sampled. Patients diagnosed with
any syndrome, including cleft lip and palate, and patients with a
history of progressive condyle resorption were excluded from the
analysis. All of these patients were surgically planned by 2DP based
on the analysis of a 2D cephalogram, conventional facial and oral
photographs, and articulator models. Preoperative multi-detector
row computed tomography (MDCT) evaluations were performed
to consider surgical procedures, but no 3D measurements or sim-
ulations were performed. In addition, CBCT was performed after a
bone healing period of at least 1 year after the operation to deter-
mine whether or not the titanium fixation plate could be removed.
Using both CT images, morphological measurements were per-
formed using the above-described method. Pre- and post-
treatment measurements were compared with a paired t-test. A
p-value of 0.05 was considered statistically significant.
3. Results
3.1. Normative ranges for 3D cephalometry in Japanese adults
A total of 56 patients were matched to normal skeletal 1 subjects
(Table 4). All landmarks were identified in all cases. The normative
ranges for the 3D cephalometric analysis of craniofacial
morphology in Japanese adults were established. Means and
standard deviations are shown in Table 5a and 5b. The gonion to
MSP and the ramus axis on the right side were slightly larger in
comparison to the left side. On average, the maxillary yaw was
within 1.0 in both male and female subjects.
The male subgroup had 10 items that were significantly (p < 0.05)
greater than those in the female subgroup (anterior facial height
[AFH], lower anterior facial height [ANS-Me], zygomatic width [ZA-
AZ], bilateral condylar width [both sides of Co-A and Co-Gn], poste-
rior facial height [PFH], and left gonial width [left side of Go to MSP]).

Table 3
Classification according to the comparison of the preoperative and postoperative Z-scores of (Zpre and Zpost).

Classification Abbreviation Definition

Deteriorated D (-1 < Zpre <1 and 1  Zpost) or (
1 < Zpre <1 and Zpost 
1)
No Improvement NI (1  Zpre and 1  Zpost) or (Zpre 
1 and Zpost 
1)
Over-treatment OT (Zpre <
1 and 1 < Zpost) or (1 < Zpre and Zpre <
1)
No Change NC (-1 < Zpre <1 and
1 < Zpost <1)
Improvement I (1  Zpre and
1 < Zpost <1) or (Zpre 
1 and
1 < Zpost <1)

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Table 5a
Definitions and measured values of 3D measurements that were corresponded to the conventional 2D cephalometric cohort, and the comparison between the present study
and a conventional 2D cephalometric cohort.

Variables Definition Present study Previous 2D study (Wada, 1977) Comparison (Present vs. previous studies)

Male Female Male vs. Female Male Female Male Female

Average SD Average SD Adjusted p-value Average SD Average SD Adjusted p-value

   
SNA Sella-Nasion-A point 80.4 3.6 81.6 2.9 0.618 81.5 3.3 80.8 3.6 0.230 0.358
angle
   
SNB Sella-Nasion-B point 77.8 3.9 78.8 2.7 0.609 78.2 4.0 77.9 4.5 0.702 0.364
angle
   
ANB SNA value - SNB value 3.0 1.4 3.1 1.3 0.905 3.2 2.4 2.8 2.4 0.702 0.560
   
FMA Angle between FH plane 29.1 5.8 29.5 5.1 0.916 28.0 2.3 30.5 2.1 0.341 0.327
and Mandibular plane
   
NAPog Angle Nasion-A point- 174.2 3.2 173.9 2.9 0.930 173.2 5.5 173.6 5.5 0.405 0.798
Pogonion
   
NSBa Nasion-Sella-Basion 131.2 4.7 132 6.0 0.844 130.1 4.3 130.2 5.9 0.356 0.254
angle
   
SN-ANSPNS Angle between Sella- 10.3 3.2 10.9 3.1 0.774 8.6 2.2 9.1 3.5 0.021 * 0.043 *
Nasion and ANS-PNS
   
Interincisal angle Angle between the axes 58.7 11.9 55.7 13.9 0.677 124.2 8.6 123.6 10.6 0.290 0.829
of the upper and lower
central incisors (average)
   
U1-SN Angle between IsU1- 72.6 10.0 74 9.1 0.867 106.0 7.5 105.9 8.8 0.547 0.966
ApU1 and Sella-Nasion
   
L1-APog Angle between IsL1-ApL1 27.3 6.0 26.4 6.7 0.829 24.5 4.3 24.9 5.3 0.045 * 0.345
and A-Pogonion

The average value and standard deviation of the Japanese 2D cephalogram were referenced from other papers. Statistically significant at *p < 0.05.

Statistical comparison of the present study with the previous
cohort (Wada, 1977) showed that 3D measurements were greater
than conventional 2D measurements in two items (an angle be-
tween the palatal plane and SN plane [SN-ANSPNS] and an incli-
nation of the lower incisors [L1-APog], p < 0.05). There were no
significant differences in the eight 3D measurements to which the
2D measurements corresponded (SNA, SNB, ANB, FMA, NAPog,
NSBa, Interincisal angle, and U1-SN).
SD, standard deviation; SNA, SeN-A angle; SNB, SeNeB angle;
FH plane, Frankfort plane; ANS, anterior nasal spine; PNS, posterior
nasal spine; MSP, mid-sagittal plane; XY plane, axial plane; Go,
gonion; GoR, right gonion; GoL, left gonion; Pog, pogonion; CoR,
right condyle; CoL, left condyle; MPR, right mastoid process; MPL,
left mastoid process; B6R, the buccal surface of the lower right first
molar; B6R, the buccal surface of the lower left first molar. Statis-
tically significant at *p < 0.05, **p < 0.01 based on Student t-test. p
Values were adjusted using the Benjamini
Hochberg false dis-
covery rate control procedure.
3.2. Evaluation of preoperative and postoperative findings in
patients treated by orthognathic surgery
A statistical comparison of pre- and post-treatment values is
shown in Table 6. The horizontal distance between the pogonion
and mid-sagittal plane (Pog to MSP; deviation of the chin) was
significantly decreased after surgery (p ¼ 0.043). In detail, eight
cases showed a value outside the normative range before treat-
ment. In six of these patients, the value “improved” to within the
normative range after surgery. In one case, Pog to MSP was within
the normative range before treatment and showed “no change”
from the normative range.
The ramus axis on the right side significantly increased
(p ¼ 0.005). In detail, four cases showed a value within the
normative range before treatment but showed a “deteriorated”
value, which was outside the normative range after treatment. In
three cases, the ramus axis was within the normative range before
treatment and showed “no change” from the normative range.
358
Regarding maxillary yaw, seven cases showed a value within the
normative range before treatment, but all showed a “deteriorated”
value. However, the statistical comparison showed no significant
differences between pre- and post-treatment values (p ¼ 0.242).
For the distance from the gonion to the mid-sagittal plane (Go to
MSP) on the right side, eight cases showed a value within the
normative range before treatment, but all showed a “deteriorated”
value that was outside the normative range after treatment.
However, the statistical comparison showed no significant differ-
ences between pre- and post-treatment values (p ¼ 0.051).
In seven cases, the ANB and FMA showed “no improvement”;
however, these values tended to improve without reaching the
normative range. The statistical comparison showed a significant
increase in the ANB after surgery (p ¼ 0.042). This was due to the
skeletal 2 tendency of the Dev subgroup.
As a representative example of the results of treatment and the
corresponding assessment, the superposition of CT images before
and after surgery in one case in the Dev subgroup (case 7) is shown
in Fig. 4. The maxillary yaw exceeds the normative range. Post-
operatively, Pog to MSP significantly improved but did not reach
the normative range in this case. Since the mandible had shifted to
the left, the position of the gonion on the non-deviated side
improved but remained out of the normative range. Surgery causes
deterioration of the twisting of the mandibular condyle axis on the
deviated side, which is within the normative range. The distortion
of the mandibular body was improved. The condyle axis on the
deviated side was twisted (Fig. 4d). In this case, the condyle axis
was classified as “deteriorated.”
4. Discussion
This study determined the normative ranges of 3D maxillofacial
morphology parameters in Japanese subjects. Due to ethical issues
that prevent CBCT images from being obtained in cases of normal
occlusion, patients who underwent CBCT for non-skeletal problems
(e.g., impacted teeth) in private orthodontic clinics using a pro-
pensity score were sampled, to match these patients with a historic

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H. Yoshikawa, C. Tanikawa, S. Ito et al. Journal of Cranio-Maxillo-Facial Surgery 50 (2022) 353e363

cohort in a report that included cephalograms of individuals with
normal occlusion (Wada, 1977). As a result, 56 patients (as the
optimal sample size) were successfully collected from a total of
1000 patients. To our knowledge, this is the first report to deter-
mine the normative range of so-called 3D cephalograms, including
parameters that can be measured only in 3D, although there have
been some reports on different parameters in individuals from
other races/ethnicities (Bayome et al., 2013; Han et al., 2019; Liang
et al., 2014; Vahdettın et al., 2016; Wang et al., 2020; Wong et al.,
2011), including left-right symmetry and mandibular axis.
Using this normative range, a new method was defined to
evaluate changes in measured values before and after treatment
into five categories. The nine patients with jaw deformity who had
undergone orthognathic surgery with 2DP were assessed to
examine the limitations of 2DP. In almost all cases, the post-
operative transverse position of the pogonion was within the
normative range, while in some cases, the maxillary yaw, the

Table 5b
Definitions and measured values of 3D measurements that did not correspond to the conventional 2D cephalometric cohort.

Variables Definitions Male Female Male vs. Female

Average SD Average SD Adjusted p-value

 
Maxillary yawing Angle between ANS-PNS and MSP on XZ plane 0.8 1.2 0.9 0.6 0.931
Go to MSP (left) Distance between Gonion and MSP (left) 48.3 mm 3.4 45.4 mm 3.1 0.018 *
Go to MSP (right) Distance between Gonion and MSP (right) 48.8 mm 3.5 46.5 mm 3.9 0.150
Pog to MSP Distance between Pogonion and MSP (right) 0.3 mm 2.6 0.2 mm 2.6 0.905
 
Ramus axis (left) Angle between Condyle-Gonion plane and MSP (left) 3.4 1.8 5.3 3.2 0.075
 
Ramus axis (right) Angle between Condyle-Gonion plane and MSP (right) 4.3 2.3 6.0 3.6 0.246
 
Mastoideus cant Angle between MPR-MPL and FH plane on XY plane 1.0 0.8 1.2 0.9 0.628
 
U6 cant Angle between U6ReU6L and FH plane on XY plane 1.2 0.8 1.1 1.0. 0.915
 
L6 cant Angle between L6R-L6L and FH plane on XY plane 1.5 1.1 1.0 0.9 0.429
 
Go cant Angle between GoR-GoL and FH plane on XY plane 1.2 1.0 1.8 1.3 0.260
 
FMA (left) Angle between Porion-Orbitale and Gonion-Menton (left) 33.4 4.7 32.8 3.5 0.871
 
FMA (right) Angle between Porion-Orbitale and Gonion-Menton (right) 31.9 4.1 33.8 3.5 0.253
 
Y-axis (left) Angle between Porion-Orbitale and Gnathion-Sella (left) 64.3 3.6 63.2 3.4 0.616
 
Y-axis (right) Angle between Porion-Orbitale and Gnathion-Sella (right) 64.0 3.1 63.0 3.3 0.609
 
Facial angle (left) Angle between Nasion-Pogonion and Porion-Orbitale (left) 86.2 2.7 86.7 2.1 0.707
 
Facial angle (right) Angle between Nasion-Pogonion and Porion-Orbitale (right) 86.7 2.2 86.9 1.8 0.930
 
FH-OcP (left) Angle between Porion-Orbitale and IsU1R-MoR (right) 23.1 3.1 24.2 4.1 0.614
 
FH-OcP (right) Angle between Porion-Orbitale and IsU1L-MoL (right) 21.3 4.5 22.7 3.4 0.591
 
SN-Mp (left) Angle between Sella-Nasion and Gonion-Menton (left) 49.1 4.9 48.5 3.9 0.853
 
SN-Mp (right) Angle between Sella-Nasion and Gonion-Menton (right) 49.2 4.8 49.0 3.5 0.924
 
Interincisal angle (left) Angle between the axes of the upper and lower central incisors (left) 59.7 11.9 56.1 14.8 0.638
 
Interincisal angle (right) Angle between the axes of the upper and lower central incisors (right) 58.1 13.1 56.0 14.0 0.878
 
L1-PoOr (left) Angle between the axis of the lower incisor Porion-Orbitale (left) 57.8 6.7 58.8 6.9 0.867
 
L1-Mp (left) Angle between the axis of the lower incisor Gonion-Menton (left) 85.7 3.4 83.5 4.0 0.190
AFH Distance between Nasion and Menton 124.3 mm 5.3 116.5 mm 6.2 <0.001 **
Co-A (left) Angle between Condyle and A 97.9 mm 3.7 93.9 mm 3.1 0.001 **
Co-Gn (left) Angle between Condyle and A 126.2 mm 3.6 121.1 mm 3.6 0.003 **
Co-A (right) Angle between Condyle and A 98.9 mm 2.7 95.1 mm 4.3 <0.001 **
Co-Gn (right) Angle between Condyle and A 127.9 mm 3.1 122.2 mm 4.8 <0.001 **
 
Condyle axis (left) Angle between innermost-outermost Condyle and MSP (left) 70.1 7.2 67.8 5.0 0.586
 
Condyle axis (right) Angle between innermost-outermost Condyle and MSP (right) 68.2 8.3 69.2 7.2 0.832
 
Occlusal plane inclination Angle between FH plane and dental occlusal plane 8.0 4.6 7.7 3.5 0.913
 
Ap1-MeIm (left) Angle between the upper-lower apex of central incisor and 71.5 4.9 73.0 5.7 0.600
Menton-antegonial notch (left)
 
Ap1-MeIm (right) Angle between the upper-lower apex of central incisor and 71.6 4.9 72.9 6.6 0.686
Menton-antegonial notch (right)
 
AB-NPog Angle between A point-B point and Nasion-Pogonion 4.6 2.1 4.4 1.9 0.838
 
SpPo-MeIm (left) Angle between Sella posterior-Nasion and Menton-antegonial notch (left) 50.2 4.0 50.1 4.5 0.936
 
SpPo-MeIm (right) Angle between Sella posterior-Nasion and Menton-antegonial notch (right) 48.3 3.8 48.2 4.8 0.932
 
SpPo-Mp (left) Angle between Sella posterior-Nasion and Gonion-Menton (left) 54.0 4.5 55.3 5.1 0.624
 
SpPo-Mp (right) Angle between Sella posterior-Nasion and Gonion-Menton (right) 52.4 4.3 53.7 4.6 0.610
 
GoMe-NPog (left) Angle between Gonion-Menton and Nasion-Pogonion (left) 69.4 3.7 68.3 3.9 0.603
 
GoMe-NPog (right) Angle between Gonion-Menton and Nasion-Pogonion (right) 69.7 4.0 68.4 4.0 0.637
 
L1-NB Angle between IsL1-ApL1 and Nasion-B 29.2 6.0 28.9 7.7 0.913
 
U1-NA Angle between IsU1-ApU1 and Nasion-A point 27.1 8.7 24.3 8.7 0.611
 
SN-GoGn (left) Angle between Sella-Nasion and Gonion Gnathion (left) 46.3 4.6 46.0 3.7 0.900
 
SN-GoGn (right) Angle between Sella-Nasion and Gonion Gnathion (right) 46.4 4.7 46.5 3.4 0.950
B6L-B6R Distance between B6L and B6R 47.8 mm 2.9 49.7 mm 4.8 0.319
ImL-ImR Distance between ImL and ImR 87.8 mm 5.6 85.1 mm 4.6 0.256
JL-JR Distance between JL and JR 91.4 mm 6.8 89.7 mm 11.5 0.829
Nasal width Distance between NL and NR 18.0 mm 2.8 18.3 mm 2.5 0.930
ZA-AZ Distance between ZA and AZ 125.3 mm 5.8 120.5 mm 4.6 0.011 *
ANS-Me Distance between ANS and Menton 70.2 mm 4.8 65.7 mm 5.1 0.014 *
PFH (left) Distance between Sella and Gonion (left) 94.1 mm 4.0 86.7 mm 5.0 <0.001 **
PFH (right) Distance between Sella and Gonion (right) 94.7 mm 4.7 87 mm 4.2 <0.001 **
AFH/PFH (left) AFH divided by PFH (right) 1.3 0.1 1.3 0.1 0.841
AFH/PFH (right) Co-A value - Co-Gn value (right) 1.3 0.1 1.3 0.1 0.690
Max-Mand (left) Co-A value - Co-Gn value (left)
27.3 mm 4.0
26.0 mm 3.8 0.659
Max-Mand (right) Distance between Sella and Gonion (left)
29.0 mm 3.8
27.2 mm 3.8 0.325

359

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H. Yoshikawa, C. Tanikawa, S. Ito et al. Journal of Cranio-Maxillo-Facial Surgery 50 (2022) 353e363

Preoperative and postoperative values, Z-scores, and the evaluation of each case in the Skeletal 2 subgroup (cases 1e3), the Skeletal 3 subgroup (cases 4e6), and the right deviation subgroup (cases 7e9). The p-value indicates the

Pre, preoperative value; Zpre, preoperative Z-score; Post, postoperative value; Zpost, postoperative Z-score; D, “deteriorated”; NI, “no improvement”; OT, “over-treatment”; NC, “no change”; I, “improvement”. Boldface type
transverse position of the gonion, mandibular yaw, and condyle

**
*

*
axis deteriorated after orthognathic surgery.

p-value

0.042
0.433
0.242
0.982
0.051
0.043
0.616
0.005
0.704
0.590
0.275
0.841
0.257
0.539
The maxillary yawing, the transverse position of the gonion,

indicates cases that deteriorated after surgery. Statistically significant at *p < 0.05, **p < 0.01 based on a paired t-test. p Values were adjusted using the Benjamini
Hochberg false discovery rate control procedure.
All
and the condyle axis are all parameters that could not be
measured by conventional 2D lateral and frontal cephalograms.

NC
NC

NC
NC
#9

NI
NI

NI

NI
NI
D
D
D
I

I
Since these parameters can be easily measured by 3D imaging, it is

NC

NC

NC
#8
suggested that 3DP therefore may be a theoretically effective

NI
NI

NI
NI

NI
NI
D

D
I

I
diagnostic modality.

Category

NC
NC

NC

NC
#7

NI

NI

NI
NI
NI
D

D
I
I
4.1. Transverse position of the pogonion

Zpost

1.3

0.8

0.4

0.9

0.9
0.3
1.4
1.6

1.8
1.4
0.6

0.2
0.5
2.3
In this study, the MSP was used, with reference to the nasion,

1.6

1.4

0.6

1.3

0.8
Zpre
sella, and FH plane, to measure the transverse position. Various

Z-score

0.6
1.6
0.4

0.6
3.1
1.6

6.8
3.7
2.4
studies have discussed the definition of the MSP, but no consensus
has been reached (Kwon et al., 2014; Vernucci et al., 2019). Proffit

mm
mm
mm
et al. suggested that the MSP be defined as the plane passing













through the sella and nasion, perpendicular to the FH plane

37.1

42.3
44.7

63.0
61.3
Post

3.2

2.4

4.9
8.2
7.0
0.7
1.3
1.8
4.2
(Proffit and White, 1991); another study reported that the same

Measurements
Dev subgroup
plane was found to be the most accurate (Damstra et al., 2012).

mm
mm
mm
As expected, the transverse position of the pogonion was cor-













rected to within the normative range after surgery in patients who

37.8

41.1
50.0

61.0
62.5
Pre

3.6

1.2

8.3
8.7
0.7
0.6
7.4
5.1
4.4
underwent surgery planned using a 2D assessment (i.e.,
anterior
posterior cephalogram).

NC
NC

NC
NC
#6

NI
NI

NI

NI
NI
D
D
D
I

I
NC

NC

NC
#5
4.2. Maxillary yaw

NI
NI

NI
NI

NI
NI
D

D
I

I
Category

NC

NC
NC

NC
#4

NI
NI

NI
NI

NI

NI
In the present study, the standard deviation of the maxillary

I
yaw (represented as the angle between the MSP and the line

Zpost

1.4

1.1

0.8

0.2
connecting the ANS and PNS) in the control group was small

0.6
0.4

0.5
0.8
0.9
0.0
0.5

0.3
1.3
0.3
(male ¼ 1.2 ; female ¼ 0.6 ), suggesting that yawing was rarely

4.7

0.3

0.9

0.3

0.1
seen in the control group. However, in seven of the nine cases Zpre
Z-score

0.1
0.7

1.5
0.9
0.1
0.1
0.9

0.7
0.5
treated after 2DP in the present study, the postoperative maxillary
yaw deteriorated from the normative range. This is because the 2D
mm
mm
mm
assessment did not include the evaluation of the maxillary yaw.












Clinically, the maxillary yaw can be evaluated using the model
32.3

42.8
44.6

19.3

77.1
71.1
Post

0.6

1.2

1.6
6.7
7.9
1.1

1.1
1.8
mounted to the articulator; but usually, the articulator cannot
Measurements
Sk 3 subgroup

reproduce the facial mid-sagittal plane, which may cause the

mm
mm
mm

deterioration of yaw after surgery.













result of comparing preoperative and postoperative values using a paired t-test for all cases.

4.6
29.9

45.7
43.9

73.1
72.8
Pre

1.5

4.1
6.8
5.6
1.1
1.9
0.9
1.3
4.3. Transverse position of the gonion
NC
NC

NC
NC
#3

NI
NI

NI

NI
NI
D

D
D

The calculated normative range from the subjects with skeletal

I

Class 1 showed that the gonion was located to the right side
NC

NC

NC
#2

NI
NI

NI
NI

NI
NI
D

D
I

(male, þ0.5 mm; female, þ1.1 mm) and that the inclination of the
Category

NC

NC

NC

NC
NC
OT
#1

NI

NI

NI

mandibular ramus on the right side was larger than that on the
D
D

D
D

left side (male, 0.9 ; female, 0.7 ). These findings are consistent
Zpost

with previous reports showing that participants with normal oc-

0.7

1.4

1.8
2.0
1.7
2.3
0.4

0.5
0.6
1.5
0.3
1.1
0.6
0.4

clusion had a wider right half of the face (Haraguchi et al., 2008).
Z-score

These results suggest that a slight right shift of the mandible can

1.8

1.7
Zpre

3.7
1.8
0.8
0.0
0.1
1.0
1.2
0.5
0.2
1.4
1.6
0.2

be accepted based on the results.

mm
mm
mm

4.4. Mandibular yaw and ramus axis













38.6

48.4
44.8

10.1

59.8
54.6
Post

5.9

3.1

1.5
6.0

1.3
2.1
1.9
1.9

In the present study, two parameters were used to evaluate the

Measurements
Sk 2 subgroup

mandibular yaw, namely the transverse position of the gonion and

mm
mm
mm

the inclination of the mandibular ramus. Both parameters showed














that the mandibular yaw deteriorated after surgery following 2DP.

39.2

46.7
47.9

57.8
55.6
Pre

8.6

1.6

2.9
7.7
6.9
1.3
2.4
2.9
1.7

Seven of nine cases showed deterioration after surgery in all three

malocclusion subgroups (i.e., the Dev, Sk2, and Sk3 subgroups).
Condyle axis (right)
Ramus axis (right)

Condyle axis (left)

Go to MSP (right)

This is also a limitation of orthognathic surgery with 2DP.

Ramus axis (left)

Mastoideus cant
Go to MSP (left)
Maxillary yaw

Pog to MSP

4.5. Condyle axis

Variables

U6 cant

Go cant
L6 cant
*FMA
Table 6

ANB

As for the condyle axis, one case (case 7, Fig. 4) in the Dev
subgroup showed deterioration of the condyle axis after surgery.
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H. Yoshikawa, C. Tanikawa, S. Ito et al. Journal of Cranio-Maxillo-Facial Surgery 50 (2022) 353e363

When the case was observed in detail, the mandibular condyle on
the deviated side was twisted outwards after surgery. This outward
rotation of the condylar axis has been reported in previous studies
(Kawamata et al., 1998; Kundert and Hadjianghelou, 1980). Tradi-
tionally, condylar displacement has been considered to have a
strong influence on postoperative stability, relapse, temporoman-
dibular joint function, joint sounds, and condylar resorption (Arnett
and Tamborello, 1992; He et al., 2019; Hwang et al., 2019). However,
a prospective follow-up study (n ¼ 60) showed that orthognathic
surgery was associated with an extremely low risk of developing
new temporomandibular joint dysfunction (Panula et al., 2000). As
such, the causal relationship between the condylar axis and the
symptoms of temporomandibular joint dysfunction has not been
clearly established. Further studies are therefore needed to clarify
whether or not the condylar axis should be corrected to within the
normative range after surgery.
4.6. Limitations
The present study had five main limitations. First, the control
group was not composed of patients with normal occlusion.
Considering the basic principle of minimizing unnecessary radia-
tion exposure, it is impossible to obtain a CBCT image of a subject
with perfectly normal occlusion and without any problems. Second,
the amount of surgical movement is not determined using only the
cephalogram value as an index. When determining the amount of
movement in surgery, comprehensive judgment is required to
obtain the best results, based on indicators such as soft tissue
balance, natural head position, risk of relapse, and the patient's
opinion. Therefore, it cannot be inferred that the deviation from the
normative range of the cephalogram has necessarily deteriorated.
Third, the deviation of the skull base reference affects the analysis.
Since being adopted in 1882 as the plane that best represents the
natural head orientation of the skull, the FH plane has also been
widely used as a reference plane in cephalometric analyses. How-
ever, the anatomically determined reference plane may deviate
from the physiologically true horizontal plane. Therefore, although
it is widely recommended to use the natural head position,
anatomical indicators can be used only in retrospective studies
using CT images taken in the past. This is a limitation of the present
study. Fourth, the changes before and after surgery include post-
operative relapse. To confirm bone healing using CBCT before
removing the fixation plate, CBCT was performed after an osseous
healing period of more than 1 year. During that time, changes may
have occurred due to relapse or postoperative orthodontic treat-
ment, including the use of intermaxillary elastics. Fifth, this was a
postoperative study that was performed in a single hospital. Since
the methods of planning orthodontic treatment and surgical pro-
cedures at different clinics are heterogeneous, different results may
be obtained from other clinics.
5. Conclusions
The present study investigated the standard skeletal
morphology of Japanese adults and the corresponding normative
range. To verify the usefulness of the standard range obtained in the
present study, the changes before and after surgery in patients who
underwent orthognathic surgery with 2DP were evaluated by five

Fig. 4. Superposition before and after surgery in one case of the right deviation group. The preoperative CT image (blue objects) and the postoperative CT image (red objects) in one
case of the left deviation group (case 7) were superimposed on the skull base. The mid-sagittal plane (MSP) was drawn as a green line. (a) Inferior view: the maxillary yaw had
deteriorated. The line connecting the ANS and PNS, which almost coincided with the MSP before surgery, had shifted after surgery. (b) Frontal view: The positions of the pogonion
and gonion on the deviated side (GoR) approached the MSP. The position of the gonion on the non-deviated side (GoL) shifted away from the MSP. (c) An inferior view of the
mandible with reference to the postoperative mandibular plane. The distortion of the triangles that constitute the mandibular plane was improved. (d) A superior view of the
mandible with reference to the postoperative mandibular plane. The condyle axis on the deviated side was twisted.
Abbreviations: ANS, anterior nasal spine; PNS, posterior nasal spine; Pog, pogonion; GoR, right gonion; GoL, left gonion; Med. CoL, left medial point of the condyle; Lat. CoL, left
lateral point of the condyle; Med. CoR, right medial point of the condyle; Lat. CoR, right lateral point of the condyle.

361

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H. Yoshikawa, C. Tanikawa, S. Ito et al.
classifications newly defined for clinical ease of use. Although the
results were obtained using preliminary data with a small sample
size, the position of the pogonion, which could be evaluated by 2DP,
was improved, while maxillary and mandibular yaw, which were
difficult to evaluate in 2DP, showed deterioration. The normative
ranges of parameters assessed in the 3D analysis of craniofacial
morphology, which were established in the present study, are
theoretically important for evidence-based 3D treatment planning
before surgery.
Funding
This work was partially supported by the Japan Society for the
Promotion of Science (JSPS) KAKENHI (grant numbers 22792048,
25862008, and 19K24071).
Data statement
The data produced and analyzed for this study are available from
the corresponding author upon reasonable request.
Declaration of competing interest
The software programs used for this study, the 3D image pro-
cessing software (Mimics Materialise), and the craniofacial surgery
planning software (Materialise ProPlan CMF), were loaned by
Materialise Japan (Yokohama).
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jcms.2022.02.002.
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