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A 3D cephalometric protocol for the accurate quantification of the craniofacial symmetry and facial growth

Pinheiro, Manuel; Ma, Xinhui; Fagan, Michael J.; McIntyre, Grant T.; Lin, Ping; Sivamurthy, Gautham; Mossey, Peter A.


Manuel Pinheiro

Michael J. Fagan

Grant T. McIntyre

Ping Lin

Gautham Sivamurthy

Peter A. Mossey


© 2019 The Author(s). Background: Cephalometric analysis is used to evaluate facial growth, to study the anatomical relationships within the face. Cephalometric assessment is based on 2D radiographic images, either the sagittal or coronal planes and is an inherently inaccurate methodology. The wide availability of 3D imaging techniques, such as computed tomography and magnetic resonance imaging make routine 3D analysis of facial morphology feasible. 3D cephalometry may not only provide a more accurate quantification of the craniofacial morphology and longitudinal growth, but also the differentiation of subtle changes in occlusion. However, a reliable protocol for the computation of craniofacial symmetry and quantification of craniofacial morphology is still a topic of extensive research. Here, a protocol for 3D cephalometric analysis for both the identification of the natural head position (NHP) and the accurate quantification of facial growth and facial asymmetry is proposed and evaluated. A phantom study was conducted to assess the performance of the protocol and to quantify the ability to repeatedly and reliably align skulls with the NHP and quantify the degree of accuracy with which facial growth and facial asymmetry can be measured. Results: The results obtained show that the protocol allows consistent alignment with the NHP, with an overall average error (and standard deviation) of just 0.17 (9.10e-6) mm, with variations of 0.21 (2.77e-17) mm in the frontonasal suture and 0.30 (5.55e-17) mm in the most prominent point in the chin. The average errors associated with simulated facial growth ranged from 1.83 to 3.75% for 2 years' growth and from - 9.57 to 14.69% for 4 years, while the error in the quantification of facial asymmetry ranged from - 11.38 to 9.31%. Conclusions: The protocol for 3D skull alignment produces accurate and landmark free estimation of the true symmetry of the head. It allows a reliable alignment of the skull in the NHP independently of user-defined landmarks, as well as an accurate quantification of facial growth and asymmetry.


Pinheiro, M., Ma, X., Fagan, M. J., McIntyre, G. T., Lin, P., Sivamurthy, G., & Mossey, P. A. (2019). A 3D cephalometric protocol for the accurate quantification of the craniofacial symmetry and facial growth. Journal of Biological Engineering, 13(1),

Journal Article Type Article
Acceptance Date Apr 19, 2019
Publication Date May 17, 2019
Deposit Date Apr 24, 2019
Publicly Available Date May 20, 2019
Journal Journal of Biological Engineering
Print ISSN 1754-1611
Publisher BioMed Central
Peer Reviewed Peer Reviewed
Volume 13
Issue 1
Public URL
Publisher URL
Contract Date May 20, 2019


Published article (1.6 Mb)

Copyright Statement
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
( applies to the data made available in this article, unless otherwise stated.

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