YIJOM-4541; No of Pages 7

Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx

https://doi.org/10.1016/j.ijom.2020.09.011, available online at https://www.sciencedirect.com

Research Paper
Imaging

Three-dimensional H. Vallen1, T. Xi1, M. Nienhuijs1,

W. Borstlap1, T. Loonen2,
B. Hoogendoorn1, L. van
Vlimmeren3, T. Maal1,2
stereophotogrammetry 1
Department of Oral and Maxillofacial
Surgery, Radboud University Medical Centre,
Nijmegen, The Netherlands; 2Radboudumc

measurement of facial 3D Lab, Department of Oral and Maxillofacial

Surgery, Radboud University Medical Centre,
Nijmegen, The Netherlands; 3Department of

asymmetry in patients with Rehabilitation, Paediatric Physical Therapy,

Radboud University Medical Centre,
Nijmegen, The Netherlands

congenital muscular torticollis:

a non-invasive method
H. Vallen, T. Xi, M. Nienhuijs, W. Borstlap, T. Loonen, B. Hoogendoorn, L. van
Vlimmeren, T. Maal: Three-dimensional stereophotogrammetry measurement of
facial asymmetry in patients with congenital muscular torticollis: a non-invasive
method. Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2020 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.

Abstract. The aim of this study was to evaluate three-dimensional (3D)

stereophotogrammetry based methods for measuring craniofacial asymmetry in
patients with congenital muscular torticollis (CMT). This study focused on the
differences in craniofacial asymmetry in CMT patients compared with a healthy
control group using 3D photographs. The difference in facial asymmetry between
the CMT group and control group was measured using two methods to analyse
facial asymmetry in distinct anatomical regions: (1) mirroring and surface-based
registration to analyse the overall facial asymmetry; (2) the ‘coherent point drift’
based method. Thirty-one patients with CMT and 84 controls were included in the
study. A statistically significant difference was found between the CMT patients and
a healthy control group. The measured facial asymmetry for the CMT group was
1.71  0.66 mm and for the controls 0.46  0.14 mm (P < 0.05). A significant
difference was found in surface ratio for the cheek, nose and the forehead region (P
Key words: 3D; congenital muscular torticollis;
< 0.05). With its minimal invasive character, 3D stereophotogrammetry is a useful facial asymmetry; stereophotogrammetry; torti-
tool in measuring the facial asymmetry associated with CMT and to quantify the collis.
treatment-induced facial changes. In the future 3D facial data could be used to
create a ranking-scale to categorize the severity of facial asymmetry. Accepted for publication 15 September 2020

0901-5027/000001+07 ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Vallen H, et al. Three-dimensional stereophotogrammetry measurement of facial asymmetry in
patients with congenital muscular torticollis: a non-invasive method, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.
YIJOM-4541; No of Pages 7
2 Vallen et al.
Congenital muscular torticollis (CMT) is
defined as a congenital deformity of the
sternocleidomastoid muscle, caused by
idiopathic fibrosis of this muscle. The
disorder results in shortening of the ster-
nocleidomastoid muscle, usually pre-
sented with hard fibrotic parts in the
affected muscle1. This process is already
established in the neonatal period2. CMT
affects the neck unilaterally and results in
a characteristic neck position in combina-
tion with a limited and restricted angular
neck range of motion. In some cases, CMT
is associated with chronic pain3. With age,
the hard-fibrotic parts subside and the
affected muscle becomes tighter. Other
clinical manifestations are musculoskele-
tal complications such as craniofacial de-
formation that will develop if the fibrotic
part of the muscle is not released4. Due to
the muscular contractions the head is tilted
to the affected side and rotated towards the
contralateral side. The chin points to the
contralateral side as well. These aspects
may induce craniofacial asymmetry,
which can result in aesthetic and function-
al problems. Craniofacial deformity fre-
quently comprises a lower position of the
ipsilateral eye, flattening of the contralat-
eral side of the occiput, ipsilateral recessed
orbit and zygoma reduction on the affect-
ed side and a different position of the chin
and ears5. The aforementioned is a clinical
description of a persistent head rotation in
one direction and head tilting in the oppo-
site direction. The facial asymmetry sig-
nificantly influences the facial aesthetics6.
Craniofacial asymmetry in patients with
CMT has been evaluated in a number of
studies. The majority of studies were per-
formed using two-dimensional clinical
photographs. In these studies facial asymme-
try and head tilting were evaluated frequent-
ly by measuring the angle between a line
drawn through the pupils and a second line
drawn through the corners of the mouth7,8.
Over the past decade three-dimensional (3D)
imaging has gained popularity as an objec-
tive tool to measure facial asymmetry9–11.
However, no literature exists in which 3D
imaging is used in the analysis of facial
asymmetry in CMT patients.
The purpose of this study was to evalu-
ate the craniofacial asymmetry in patients
with CMT and to compare this data with a
healthy control group using 3D stereopho-
togrammetry. Two different methods of
measuring facial asymmetry were used
and the results were compared.
Materials and methods
In this retrospective study patients with
CMT were included who underwent sur-
Please cite this article in press as: Vallen H, et al. Three-dimensional stereophotogrammetry measurement of facial asymmetry in
patients with congenital muscular torticollis: a non-invasive method, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.
gical release of the sternocleidomastoid
muscle combined with physiotherapy at
the department of Oral and Maxillofacial
(OMF) surgery of Radboud University
Medical Centre in Nijmegen in the period
between May 2012 and June 2019.
Patients with proven anomalies in the neck
(e.g., a block vertebra or other neck pro-
blems), facial trauma, or previous facial
surgery were excluded. The control group
consisted of randomly selected 3D photo-
graphs, out of a database of healthy volun-
teers with no history of facial surgery or
existing facial deformities, and were
matched to the exact age and gender of
distribution of the CMT patients. The
CMT patients as well as the control group
were divided by gender and age (0–4
years, 5–9 years and >10 years) in six
independent subgroups. The collected data
were de-identified and anonymized prior
to analysis. All parents of the patients gave
their informed consent to this study. The
study was waived for approval by the
Institutional Review Board.
Data Acquisition
Three-dimensional photographs were ac-
quired using a stereophotogrammetrical
camera set-up (3dMDfaceTMSystem;
3dMD LLC, Atlanta, GA, USA). All
photographs were taken at the intake, prior
to treatment, at the department of Oral and
Maxillofacial Surgery. Patients were po-
sitioned in natural head position during
image acquisition with their head in an
upright posture, the eyes focused on a
point in the distance at eye level, which
implies that the visual axis is horizontal12.
The 3D photographs were used to analyse
the severity of the facial asymmetry. In
this study two different methods to analyse
the asymmetry were used. The first meth-
od used mirroring and surface-based reg-
istration to analyse the overall facial
asymmetry described by Verhoeven
et al.10. The second method used a more
complex analysis method (based on coher-
ent point drift) to analyse facial asymme-
try in distinct anatomical regions earlier
described by Brons et al.13.
Overall Facial Asymmetry Analysis
To analyse the overall facial asymmetry,
all 3D photographs were processed prior
to analysis in four consecutive steps, as
follows.
Exclusion of the confounding areas
To exclude confounding regions, the neck,
ears and hair were removed using 3dMD
patient v3.1.0.3 (3dMD patientTM Soft-
ware Platform, 3dMD LLC). The neck
was excluded below the thyroid cartilage
and laterally from the sternocleidomastoid
muscle.
Creating a mirrored 3D facial surface
The 3D facial image (OBJ-file) was
imported into a computer program Max-
ilim1 (Medicim NV, Mechelen,
Belgium). In this program the midsagittal
plane was constructed (a plane perpendic-
ular to the coronal plane and through
nasion (N) and subnasale (Sn)) and used
to create a mirrored 3D photograph, result-
ing in an original and a mirrored 3D
photograph.
Initial alignment of the original and
mirrored facial surface
In Maxilim1 the original and the mir-
rored facial surface were roughly aligned
using four manually chosen landmarks
(exocanthion right, exocanthion left, sell-
ion and subnasale).
Surface Registration
After initial alignment, the complete facial
surface was used as a surface registration
area. Surface registration of the original
and mirrored images was automatically
established using the Iterative Closest
Point Algorithm (ICP)14. The Iterative
Closest Point Algorithm searches for the
closest point-to-point relationship be-
tween two surfaces in both images. The
maximum search radius was set at 1 mm
for the ICP algorithm. After the surface
registration was completed, a colour-cod-
ed distance map was generated to illustrate
the differences between the two surfaces
(inter-surface distance). This colour-cod-
ed distance map represents the measure for
facial asymmetry. From this colour-coded
distance map, the measured distances
were exported. The mean distance in milli-
meters was calculated using Matlab1
(R2007a, Mathworks, Natick, MA,
USA), as a direct measurement of facial
asymmetry10.
Regional Facial Asymmetry
A second method for measuring facial
asymmetry is based on the Coherent Point
Drift (CPD) algorithm13. This method
measures demarcated aesthetic units of
the human face. The CPD-algorithm pro-
vides a method for analysing facial defor-
mity and evaluating localized growth
disruption over time.
This method consists of different con-
secutive steps:
YIJOM-4541; No of Pages 7

Three-dimensional stereophotogrammetry measurement of facial asymmetry in patients 3

Fig. 1. Translation of the facial template to the three-dimensional (3D) photograph. (A) The template face segmented into the 18 aesthetic units.
(B) For this study selected regions for the evaluation of facial asymmetry (green – forehead; yellow – lateral part of the nose; purple – cheek; blue –
periorbital region including the zygoma). (C) The facial aesthetic units (contours indicated by black lines) visualized on the original cropped 3D
photograph of one of the patients included in this study.

1. Composing a template face
A template face was created using 30
3D photographs of healthy volunteers. The
3D photographs were rigidly aligned
based on five manually placed landmarks
(i.e. pupil left and right, cheilion left and
right, and the pronasale). All 30 3D photo-
graphs were superimposed on a facial
template and an average face was created.
This average face formed the 3D reference
face for further analysis. Using Autodesk
Meshmixer (Version 10.9.332, Autodesk
Inc., San Rafael, CA, USA), the reference
face of the healthy volunteers was divided
into 18 aesthetic units, symmetrically di-
vided in the right and left side of the
reference face (Fig. 1).
2. Scaling the reference face and crop-
ping individual 3D photographs
In Matlab1, the height and width of the
reference face was automatically scaled to
the individual 3D photograph of the patients
and controls included in the study. The
surface outside the reference face (hair
and ears) was automatically removed to
match its extent to that of the reference face.
3. Translation of the template face to the
test person’s 3D photographs
The scaled reference face, including the
predefined facial aesthetic units, were sub-
sequently matched on top of the subject’s
cropped 3D photograph using the CPD
algorithm15. In this study four regions of
the reference face (the forehead, the peri-
orbital region including the zygoma, the
cheek and the lateral part of the nose) in
which the highest variation in facial asym-
metry was expected between CMT
patients and the standardized reference
face were analysed (Fig. 1). The two facial
aesthetic units in the zygoma region were
combined. Next, the programme com-
pared the surface of the selected regions
to the corresponding regions of the refer-
ence face in the opposite part of the 3D
photograph. For example, the facial fore-
head part on the right side was compared
with the facial forehead part on the left
side. For the statistical analysis, the mea-
sured surface ratio for these facial surfaces
was calculated (the largest surface of the
selected region divided by the smaller
surface of the corresponding region on
the opposite site).
Statistical analysis
The described methods were applied to the
3D photographs of the control group and
the patients. Mean, standard deviation
(SD), standard error (SE), medians (inter-
quartile range), and ratios (proportions)
were calculated. Anonymized data were
prepared and entered in IBM SPSS Statis-
tics for Windows, version 25.0 (IBM
Corp., Armonk, NY, USA). The Chi-
squared test was used for comparing cate-
gorical variable (gender) between groups.
Independent t-tests were performed to an-
alyse the facial asymmetry in the CMT
patients compared with the reference con-
trol group. The level of significance was
determined at a P-value below 0.05.
Results
Initially, a total of 49 patients were includ-
ed in the torticollis group. Eighteen 3D
Table 1. Total sample for the 1-mm surface-based method and the Coherent Point Drift (CPD)
algorithm in three-dimensional photographs.
CMT group (1-
mm method and
CPD-algorithm)
Population 31
(n = 115)
Sex Boy Girl
Age at baseline
(years)
0–4 3 4
5–9 4 5
10 6 9
Total 13 18
photographs were excluded due to the
following reasons: not usable because of
hair overlaying the patient’s forehead, not
showing a relaxed face or missing surfaces
on the image. After exclusion, a total of 31
patients remained. These 31 patients were
compared with 84 3D photographs of the
control group. Subgroups were made for
the patients as well as for the control group
dividing the gender and age categories
into six independent groups.
In total 31 patients and 84 controls were
eligible for further analysis. The torticollis
group consisted of 13 boys and 18 girls
(boy versus girl ratio 1:1.38) with a mean
age of 8.9  5.2 (SD) years (girls 8.9 
5.3 years; boys 8.8  5.2 years). The age
of the patients varied from 1 year to 19
years. The control group consisted of 39
boys and 45 girls (boy versus girl ratio
1:1.15) with a mean age of 7.2  4.3 years
(girls 7.2  4.1 years; boys 7.2  4.6
years). No significant difference was seen
in age or gender between the groups (P
= 0.08 and P = 0.67, respectively) (Tables
1 and 2).
Overall Facial Asymmetry
A total of 31 patients in the torticollis
group were compared with 84 patients
Control group (1- Control group
mm method) (CPD-algorithm)
84 76
Boy Girl Boy Girl
15 15 13 13
9 15 8 15
15 15 15 12
39 45 36 40

Please cite this article in press as: Vallen H, et al. Three-dimensional stereophotogrammetry measurement of facial asymmetry in
patients with congenital muscular torticollis: a non-invasive method, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.
YIJOM-4541; No of Pages 7

4 Vallen et al.

Table 2. Difference in facial asymmetry related to age. 0.16 mm) was found (P < 0.001). The
Age Group n Mean SD SE t P children of 10 years or older (age category
3) showed similar results. There was a
0–4 CMT 7 1.49 0.58 0.22 4.912 P = 0.003
Control 30 0.42 0.10 0.02 significant difference in mean facial asym-
5–9 CMT 9 1.86 0.73 0.24 5.714 P < 0.001 metry found (P < 0.001) comparing the
Control 24 0.45 0.16 0.03 torticollis group with 15 patients (mean
10 CMT 15 1.73 0.66 0.17 7.050 P < 0.001 facial surface 1.73  0.66 mm) with the
Control 30 0.51 0.14 0.03 control group (mean facial surface 0.51 
CMT, congenital muscular torticollis; SD, standard deviation; SE, standard error. 0.14 mm) as well.

Regional Facial Asymmetry

in the control group. The measured overall
facial asymmetry (mean  SD) for the
complete torticollis group was 1.71 
0.66 mm and for the complete control
group 0.46  0.14 mm. The difference be-
tween the groups was statistically signifi-
cant (P < 0.001). A larger range in
measured facial asymmetry is seen in
the torticollis group compared with the
control group (Fig. 2).
Subsequently, subgroups were made
based on age but without stratification
between boys and girls. A slight increase
in asymmetry was seen over the years in
Fig. 2. Box plot showing the absolute mean asymmetry in total control group and congenital
muscular torticollis (CMT) group.
both the torticollis and the control groups.
Children of the age 0–4 years (age cate-
gory 1) showed in seven torticollis patients
a mean facial asymmetry of 1.49 
0.58 mm compared with 30 control
patients with a mean facial asymmetry
of 0.42  0.10 mm (P = 0.003). Children
of the age 5–9 years (age category 2),
showed more variation in the torticollis
group with nine patients for the mean
facial asymmetry. A significant difference
between the torticollis group (mean facial
surface 1.86  0.73 mm) and the control
group (mean facial asymmetry 0.45 
All 3D photographs were examined using
the CPD algorithm as described by Brons
et al. to analyse in which part of the face
most asymmetry occurred. The CPD-algo-
rithm measured surface ratios specified for
the aforementioned four demarcated
regions of the human face. A total of 31
patients in the torticollis group were com-
pared with the control group. Eight more
3D photographs in the control group were
excluded because the template did not
match the regions of interest in the CPD
algorithm, resulting in the inclusion of 76
subjects in this group. The measure of
asymmetry is the ratio between the largest
and the smallest surface. Comparing the
torticollis group with the control group in
total, without stratification for gender or
age, a statistically significant difference
was found in surface ratio for the cheek,
nose and the forehead region (P = 0.005,
P = 0.014 and P = 0.002, respectively)
(Fig. 3).
Subsequently, the subgroups based on
age were analysed without stratification
between boys and girls. Children of the
age 0–4 years (age category 1) showed a
statistically significant difference between
facial surface ratio only in the cheek re-
gion (P = 0.013). In children of the age 5–
9 years (age category 2) a significant
difference in facial surface ratio was seen
in the cheek (P = 0.010), nose (P = 0.005)
and the forehead region (P = 0.03). The
children of 10 years or older (age category
3) showed a significant difference in facial
surface ratio in the nose (P = 0.013) and in
the forehead region (P = 0.028) (Fig. 4).

Discussion
The purpose of this study was to evaluate
whether 3D stereophotogrammetry can be
used to objectively measure craniofacial
asymmetry in patients with CMT. Al-
though the use of 3D stereophotogramme-
try is more and more accepted and used in
clinical daily practice16, analysis of 3D
images of patients with CMT to a gender-
Fig. 3. Box plot showing the facial surface ratio for the four regions of the face for the control and age-matched reference human face
group and congenital muscular torticollis (CMT) group. has not yet been performed.

Please cite this article in press as: Vallen H, et al. Three-dimensional stereophotogrammetry measurement of facial asymmetry in
patients with congenital muscular torticollis: a non-invasive method, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.
YIJOM-4541; No of Pages 7
Three-dimensional stereophotogrammetry measurement of facial asymmetry in patients
Fig. 4. Box plot showing the facial surface ratio for four regions of the face for the control
group and congenital muscular torticollis (CMT) group subdivided into age categories.
Craniofacial asymmetry in patients with
CMT has been evaluated in several stud-
ies, mainly using 2D clinical photographs.
These studies evaluated facial asymmetry
and head tilting on 2D photographs by
measuring the angle between a line drawn
through the pupils and a second line drawn
through the corners of the mouth7,8. Other
researchers tried to define a classification
to grade the severity of torticollis using the
degree of limitation of neck rotation or
Please cite this article in press as: Vallen H, et al. Three-dimensional stereophotogrammetry measurement of facial asymmetry in
patients with congenital muscular torticollis: a non-invasive method, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.
head tilting. Postsurgical changes of these
parameters were analysed17,18.
In the last decade, much research has
been performed to evaluate craniofacial
asymmetry using 3D images. Akhil et al.
performed a systematic review of the as-
sessment of facial asymmetry using 3D
tools. In their study, they emphasize that
conventional diagnostic radiographs have
limitations in asymmetry diagnosis be-
cause of their 2D assessment of a 3D
5
image. Magnification, distortion and pro-
jection errors which are more common in
2D images, are reduced by the advent of
3D images. This is exactly the reason why
we believe that the evaluation of facial
asymmetry should be performed using 3D
imaging. Several studies evaluated facial
asymmetry using imaging techniques such
as CT (computed tomography) or CBCT
(cone beam CT)19. The main disadvantage
of these techniques is that the patients are
exposed to radiation. On the contrary, 3D
stereophotogrammetry is known as an ac-
curate and valid method to capture 3D
images of the face9–11,20. The most impor-
tant advantage of 3D stereophotogramme-
try is that it is a noninvasive technique and
it does not expose the patient to radiation.
Not only is 3D stereophotogrammetry ac-
curate in capturing 3D facial images, more
advantages are known. For example, the
rapid acquisition time, which is helpful in
young children who are harder to instruct
not to move during the acquisition of an
image.
In the literature several methods were
described to analyse facial asymmetry on
3D photographs or surface scans. A num-
ber of studies evaluated facial asymmetry
using 3D cephalometric landmarks indi-
cated on 3D photographs10,21,22. Verhoe-
ven et al.10 and Ekrami et al.23 measured
facial asymmetry in 3D stereophotogram-
metry by matching the original surface
with a mirrored surface without the use
of landmarks and excluding the neck, hair
and ears. In their study Verhoeven et al.
also performed a comparative validation
study of different methods to analyse fa-
cial asymmetry on 3D photographs. The
results of their study showed that surface-
based methods such as the one used in this
study were valid and highly reproducible
and performed superiorly in comparison
with the landmark-based method for the
quantification of soft tissue facial asym-
metry. They concluded that this method
(called the 1-mm method) is reproducible
and accurate in the quantification of facial
asymmetry of soft tissue and is therefore
chosen to be the gold standard for clinical
application10.
Measuring asymmetry on 3D photo-
graphs or surface scans by matching the
original and the mirrored face without the
use of landmarks has been done before24.
Almost all studies in which this method is
applied used the ICP algorithm14 to obtain
an objective measure of facial asymme-
try10. These methods were used for re-
search purposes as well as in daily
clinical practice. Earlier studies described
the use of this technique in cleft patients25–
27
, to evaluate orthodontic treatment28,29,
YIJOM-4541; No of Pages 7
6 Vallen et al.
to evaluate asymmetric changes during
adolescent growth30, to evaluate possible
gender differences31, to evaluate the treat-
ment effect in children with hemangio-
ma32, to evaluate asymmetry in patients
with hemifacial microsomia33 and facial
palsy.34 Dindaroglu et al. demonstrated
that the use of 3D photographs allows
an accurate quantification of the surface
of the facial soft tissue20. Three dimen-
sional photographs can be analysed using
surface-based registration, whereafter
these photographs can be matched at dif-
ferent treatment stages. Differences can be
visualized by generating a colour-coded
distance map between the 3D photo-
graphs35.
Recent developments to assess facial
asymmetry have focused on more complex
superimpositioning algorithms and statisti-
cal shape models. In this way, it is easier to
focus on facial shape changes and perform
more complex facial analysis.
In the literature, no clear consensus can
be found in the ratio of CMT between boys
and girls. However there appears to be a
slight male predominance with a relative
ratio of 3:236. Our study consisted of 13
boys and 18 girls (boy versus girl ratio
1:1.38) and therefore did not show the
male predominance as described by Lee
et al. Creating subgroups for gender
causes even smaller group sizes and
may introduce selection bias. The results
of this study should therefore be inter-
preted with care considering the small
sample size of different CMT age groups.
For this reason, the study first examined
differences between CMT patients and the
control group in total. Thereafter, sub-
groups were made based only on age
and not on gender.
In the presented study, the overall facial
asymmetry was analysed as well as the
facial asymmetry present in different ana-
tomical regions. The method used to evalu-
ate the overall facial asymmetry requires a
correct and complete 3D photograph of the
face. A shortcoming of the 3D photographs
initially included in the study was that the
forehead region was covered with hair in
some of the 3D photographs. Other limita-
tions were 3D photographs in which the
facial musculature was not relaxed or miss-
ing surfaces on the image. Unfortunately,
this resulted in the exclusion of 18 3D
photographs. Using the described methods
to analyse the facial asymmetry, this study
only examined asymmetry of the face itself,
not noticing the neck or the position of the
head compared with the body. As the prob-
lem in CMT patients originates from the
neck, this would be an important part of the
body to analyse in more detail. Several
Please cite this article in press as: Vallen H, et al. Three-dimensional stereophotogrammetry measurement of facial asymmetry in
patients with congenital muscular torticollis: a non-invasive method, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.
authors have tried to make a classification
to grade the severity of torticollis using the
degree of limitation of neck rotation or head
tilting17,18. Whether the limitation of rota-
tion of the neck or amount of head tilt is
correlated with the severity of facial asym-
metry has not been investigated in detail up
until now. Unfortunately, it is hard and
cumbersome to acquire accurate 3D photo-
graphs of the neck anatomy which could be
used for further analysis. More fundamental
research is required to investigate whether
3D stereophotogrammetry could be of use
to analyse and differentiate between normal
and affected neck anatomy.
The second method used in this study
focused on regional facial asymmetry using
the CPD algorithm as described by Brons
et al.13. In this study we chose to measure
the surface ratios of four lateral regions of
the human face in which the highest varia-
tion in facial asymmetry was expected be-
tween CMT patients and the control group.
We hypothesized that for the torticollis
patients the affected side always had a
smaller surface area compared with the
non-affected side. From the analysis of
the initial results we found that this was
only the case for the nose region. In the nasal
area, 25 of the total 31 patients had a surface
ratio larger than 1 (affected side: non-af-
fected side). Therefore, we had to abandon
our initial hypothesis. The measure of re-
gional asymmetry was therefore defined by
the ratio between the largest and the smal-
lest surface. Another limitation of the meth-
od used to analyse regional asymmetry was
that in a limited number of healthy controls,
the border of some of these aesthetic units
did not match the template placed by the
CPD algorithm covering the 3D photo-
graph. This caused a distorted template
and made the captured image unusable.
Exclusion of eight of these non-usable
photographs caused a decline in the number
of subjects in the study control population.
The results of the presented study illus-
trate that there is a significant difference in
facial asymmetry between the CMT
patients and the healthy control group.
This study did not investigate the position
of the head in relation with the spine.
However, earlier studies proved that the
position of the head in relation to the spine
does change over time37. Apart from head
positioning, there are more parameters
that could influence facial asymmetry.
For example, the growth of the skull,
the age and the quantity of the affected
fibers in the sternocleidomastoid muscle
could all cause a difference in expression
of CMT. For this reason, subgroups were
created to stratify the study population by
age. From the analysis of the different age
groups it was seen that increasing age
correlated with a slight increase in facial
asymmetry in the torticollis patients as
well for the healthy control group. Fur-
thermore, a larger variation in facial asym-
metry was observed for the facial aesthetic
regions. In particular, in the second age
group the deviation of asymmetry was
relatively large for the aesthetical regions.
Lee et al. described that better results were
found when surgical treatment was exe-
cuted before 5 years of age18. However,
Lee GS et al. describes that craniofacial
asymmetry appears after 5 years of age38.
In our study, most facial asymmetry is
seen after five years of age. Therefore,
surgery seems to be an effective treatment
in prevention of any craniofacial asymme-
try during early childhood, especially at
the age range of 1–4 years.
From this study it can be concluded that
3D stereophotogrammetry is an effective
method to capture 3D images of the face in
torticollis patients. With the methods pro-
posed in this study the changes in facial
asymmetry can be measured in an objec-
tive manner. In the future, 3D facial data
can be used to create a ranking-scale. In
this way, it would be possible to classify
the face and the severity of the disease and
facial asymmetry and to divide them into
different categories.
Such a classification will hopefully aid
in objectively determining the amount of
facial asymmetry and moreover the effec-
tiveness of the therapy. In the end a data-
base with a large amount of included 3D
data of patients can provide new patients
with treatment guidance. We propose to
use standardized 3D surface imaging tech-
niques to be integrated in the standardized
documentation datasets for the evaluation
of outcome of CMT treatment.
Funding
None.
Competing interests
None.
Ethical approval
Ethical approval from the Institutional
Review Board CMO Radboudumc was
waived.
Patient consent
Written patient consent was been
obtained.
YIJOM-4541; No of Pages 7

Three-dimensional stereophotogrammetry measurement of facial asymmetry in patients 7

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Please cite this article in press as: Vallen H, et al. Three-dimensional stereophotogrammetry measurement of facial asymmetry in
patients with congenital muscular torticollis: a non-invasive method, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.