Does facial asymmetry vary between subjects of different age groups? A 3D stereophotogrammetry analysis.

This study was aimed to assess whether facial asymmetry increases with age and to examine potential gender differences using 3D stereophotogrammetry. A prospective cross-sectional study was performed. 3D photographs were acquired from 600 control subjects, 300 male, 300 female, and were stratified into 15 different age groups ranging from 0 to 70+. The 3D photographs were postprocessed and mirrored. The original and mirrored faces were surface-based matched using an iterative closest point algorithm. The primary outcome variable, facial asymmetry, was evaluated by calculating the absolute mean distance between the original and mirrored images. The primary predictor was age. Pearson's correlation was used to assess the correlation between facial asymmetry and age. The average overall facial asymmetry was 0.72 mm (SD 0.72 mm; range 0.25 - 3.04 mm). Mean facial asymmetry increased significantly with age, from 0.45 mm in the age group of 0-4 years to 0.98 mm in the age group of 70+ (p<0.001). Facial asymmetry was positively correlated with age (Pearson's r = 0.55; p<0.001). Male subjects were significantly more asymmetric compared to females, 0.77 mm and 0.67 mm, respectively (p<0.001). This study indicates that facial asymmetry significantly increases with age and is significantly larger in males than in females.

[The 3D-printed surgical guides used during genioplasty]. / De 3D-geprinte zaag- en repositiemal voor een kinplastiek.

Genioplasty is a seemingly simple procedure performed to correct the bony chin. The results of the procedure are, however, strongly correlated with the experience of the surgeon. 3D-printed surgical guides could act as a transfer modality to translate the preoperative planning directly into the achieved result. Prospective studies evaluating the usefulness of the 3D-printed surgical guides have not yet been carried out and consensus regarding the best design is lacking. In order to become more familiar with working with surgical guides, a genioplasty using 3D-printed surgical guides was performed. The postoperative analysis of the achieved result showed minor differences compared to preoperative planning. Surgical guides have the potential to improve the accuracy and predictability of genioplasty. The design should be further refined and the added value of the guides should be confirmed by means of prospective research.

Critical appraisal of patient-specific implants for secondary post-traumatic orbital reconstruction.

In orbital reconstruction, a patient-specific implant (PSI) may provide accurate reconstruction in complex cases, since the design can be tailored to the anatomy. Several design options may be embedded, for ease of positioning and precision of reconstruction. This study describes a cohort of 22 patients treated for secondary orbital reconstruction with a PSI; one patient received two PSI. The preoperative clinical characteristics and implant design options used are presented. When compared to preoperative characteristics, the postoperative clinical outcomes showed significant improvements in terms of enophthalmos (P < 0.001), diplopia (P < 0.001), and hypoglobus (P = 0.002). The implant position in all previous reconstructions was considered inadequate. Quantitative analysis after PSI reconstruction showed accurate positioning of the implant, with small median and 90th percentile deviations (roll: median 1.3°, 90th percentile 4.6°; pitch: median 1.4°, 90th percentile 3.9°; yaw: median 1.0°, 90th percentile 4.4°; translation: median 1.4 mm, 90th percentile 2.7 mm). Rim support proved to be a significant predictor of roll and rim extension for yaw. No significant relationship between design options or PSI position and clinical outcomes could be established. The results of this study show the benefits of PSI for the clinical outcomes in a large cohort of secondary post-traumatic orbital reconstructions.

Registration-free workflow for electromagnetic and optical navigation in orbital and craniofacial surgery.

The accuracy of intra-operative navigation is largely dependent on the intra-operative registration procedure. Next to accuracy, important factors to consider for the registration procedure are invasiveness, time consumption, logistical demands, user-dependency, compatibility and radiation exposure. In this study, a workflow is presented that eliminates the need for a registration procedure altogether: registration-free navigation. In the workflow, the maxillary dental model is fused to the pre-operative imaging data using commercially available virtual planning software. A virtual Dynamic Reference Frame on a splint is designed on the patient's fused maxillary dentition: during surgery, the splint containing the reference frame is positioned on the patient's dentition. This alleviates the need for any registration procedure, since the position of the reference frame is known from the design. The accuracy of the workflow was evaluated in a cadaver set-up, and compared to bone-anchored fiducial, virtual splint and surface-based registration. The results showed that accuracy of the workflow was greatly dependent on tracking technique used: the workflow was the most accurate with electromagnetic tracking, but the least accurate with optical tracking. Although this method offers a time-efficient, non-invasive, radiation-free automatic alternative for registration, clinical implementation is hampered by the unexplained differences in accuracy between tracking techniques.

Surgical instrument to improve implant positioning in orbital reconstruction: a feasibility study.

Adequate positioning of an orbital implant during orbital reconstruction surgery is essential for restoration of the pre-traumatised anatomy, but visual appraisal of its position is limited by the keyhole access and protruding soft tissues. A positioning instrument that attaches to the implant was designed to provide feedback outside the orbit. The goal of this study was to evaluate the accuracy of placement with the instrument and compare it with the accuracy of placement by visual appraisal. Ten orbits in five human cadaver heads were reconstructed twice: once using visual appraisal and once using the instrument workflow. No significant improvement was found for the roll (5.8° vs 3.4°, respectively, p=0.16), pitch (2.1° vs 1.5°, p=0.56), or translation (2.9 mm vs 3.3 mm, p=0.77), but the yaw was significantly reduced if the instrument workflow was used (15.3° vs 2.9°, p=0.02). The workflow is associated with low costs and low logistical demands, and may prevent outliers in implant positioning in a clinical setting when intraoperative navigation or patient-specific implants are not available.

Quality of life of patients with 3D-printed arm prostheses in a rural area of Sierra Leone.

INTRODUCTION: In Sierra Leone, access to prostheses is limited due to absence of practical knowledge, materials, trained staff, and high cost. This paper investigates the impact of a 3D printed prosthesis on the health-related quality of life (HRQoL) in prosthesis recipients. METHODS: Patients with upper extremity amputations were included in this case study from December 2018 until July 2019. Data on the HRQoL was gathered until April 2020 in Masanga Hospital, central rural Sierra Leone. At two follow-up moments the HRQoL was assessed by applying the standard EQ-5D-5L questionnaire. These two follow-up moments varied between one week and just over a year after receiving the prosthesis. A second patient questionnaire was used to assess prosthesis satisfaction. RESULTS: Seven patients were included. The results of the EQ-5D-5L questionnaire show no deterioration of the HRQoL in any patient and the overall HRQoL increased by almost 20% compared to the null measurement. One patient was lost to follow up after the first re-visit. The responses to the second questionnaire indicated that patients are satisfied with the prosthesis and use it in various situations. Patients often mentioned they feel more included in society when wearing the prosthesis. One patient says wearing the prosthesis helped in accepting the amputation. As a result, enough self-confidence was experienced without the prosthesis and the patients stopped wearing the prosthesis. DISCUSSION: The overall HRQoL in patients wearing a 3D-printed prosthesis increases compared to not wearing one. Assessing the HRQoL at regular intervals is important for the long-term follow-up and to safeguard sustainability and long-term success of this project. Nevertheless, defining the HRQoL is challenging due to cultural differences and misunderstandings. Therefore, the use of alternative questionnaires to define the HRQoL should be investigated. To improve and warrant long-term success, identifying long-term problems is important, and the second questionnaire accounts for this need.

Virtual splint registration for electromagnetic and optical navigation in orbital and craniofacial surgery.

In intra-operative navigation, a registration procedure is performed to register the patient's position to the pre-operative imaging data. The registration process is the main factor that determines accuracy of the navigation feedback. In this study, a novel registration protocol for craniofacial surgery is presented, that utilizes a virtual splint with marker points. The accuracy of the proposed method was evaluated by two observers in five human cadaver heads, for optical and electromagnetic navigation, and compared to maxillary bone-anchored fiducial registration (optical and electromagnetic) and surface-based registration (electromagnetic). The results showed minimal differences in accuracy compared to bone-anchored fiducials at the level of the infra-orbital rim. Both point-based techniques had lower error estimates at the infraorbital rim than surface-based registration, but surface-based registration had the lowest loss of accuracy over target distance. An advantage over existing point-based registration methods (bone-anchored fiducials, existing splint techniques) is that radiological imaging does not need to be repeated, since the need for physical fiducials to be present in the image volume is eradicated. Other advantages include reduction of invasiveness compared to bone-achnored fiducials and a possible reduction of human error in the registration process.

Characterizing the face in facioscapulohumeral muscular dystrophy.

OBJECTIVE: To evaluate facial weakness in patients with FSHD to better define clinical signs, and pilot a facial weakness severity score. METHODS: 87 FSHD patients and 55 controls were video recorded while performing seven facial tasks. The videos were assessed by three independent examiners to compile an overview of signs of facial weakness. Next, videos were semi-quantitatively assessed using a newly developed 4-point facial weakness score (FWS). This score was evaluated and correlated to other FSHD disease characteristics. RESULTS: Patients had lower scores on the total FWS than controls (mean score 43 ± 28, range 4-118, vs 14 ± 9, range 0-35, p < 0.001) and on all seven individual facial tasks (all p < 0.001). 54% of patients had FWS scores outside the range of controls. Patients had more asymmetry between the left and right side of the face than controls. About 10% of the patients had very mild facial weakness. These were mostly males (89%) with longer D4Z4 repeat sizes of 7-9 units. More severe facial weakness correlated to more severe overall disease severity and shorter D4Z4 repeat size, but not to disease duration. Interobserver agreement for the FWS between three raters was low with a Fleiss Kappa of 0.437. CONCLUSION: This study provides an overview of the clinical spectrum of facial weakness and its relation to other disease characteristics. The 4-point scale we introduced to grade the severity of facial weakness enables correlation of facial weakness to disease characteristics, but is not suited as clinical outcome measure for longitudinal studies.

Nasolabial shape and aesthetics in unilateral cleft lip and palate: an analysis of nasolabial shape using a mean 3D facial template.

The aim of this study was to determine the amount of deviation in nasolabial shape in patients with a cleft compared with an average non-cleft face, and to assess whether this difference is related to nasolabial aesthetics. Three-dimensional stereophotogrammetric images of 60 patients with a unilateral cleft were used. To quantify shape differences, four average non-cleft faces were constructed from stereophotogrammetric images of 141 girls and 60 boys. Three-dimensional shape differences were calculated between superimposed cleft faces and the average non-cleft face for the same sex and age group. Nasolabial aesthetics were rated with the modified Asher-McDade Aesthetic Index using a visual analogue scale (VAS). Mean VAS scores ranged from 51.44 to 60.21 for clefts, with lower aesthetic ratings associated with increasing cleft severity. Shape differences were found between cleft faces and the average non-cleft face. No relationship was found for the VAS, age, and sex, except that a lower VAS was related to a higher nose and lip distance between the superimposed cleft and average non-cleft faces for nasal profile (P= 0.02), but the explained variance was low (R2=0.066). In conclusion, except for nasal profile, nasolabial aesthetics were not influenced by the extent of shape differences from the average non-cleft face.

Symmetry of palatal shape during the first year of life in healthy infants.

OBJECTIVES: The purpose of this study was to quantify the symmetry of the alveolar process of the maxilla and palate during the first year of life in healthy infants with the help of a semiautomatic segmentation technique. MATERIALS AND METHODS: Maxillary plaster models of seventy healthy babies at 0, 3, 6, 9, and 12 months were collected and digitized. A semiautomatic segmentation tool was used to extract the alveolus and palate. The resulting model was aligned within a reference frame and mirrored on its medial plane. Distance maps were created and analyzed to compare and quantify the differences between the two hemispheres. Additional hemispherical width and area measurements were performed. An ANOVA test with additional post hoc tests was performed to check if the symmetry changed during development. Finally, the results were tested on intra- and interobserver variability. RESULTS: The absolute mean inter-surface distance between the original and mirrored models in each age group ranged between 0.23 and 0.30 mm. Width and area analysis showed a small but significant larger left palatal hemisphere. ANOVA and post hoc tests showed no significant difference in symmetry between groups. Reliability analysis showed no significant differences between observers. CONCLUSIONS: This study showed that in this infant population, only a small degree of palatal asymmetry was present, which can be considered as normal and clinically irrelevant. CLINICAL RELEVANCE: The data from this study can be used in future comparative studies as reference data. Furthermore, modeling of these data can help in predicting the growth pattern, which may lead to improved treatment protocols for children with craniofacial anomalies.

Fusion of intra-oral scans in cone-beam computed tomography scans.

PURPOSE: The purpose of this study was to evaluate the clinical accuracy of the fusion of intra-oral scans in cone-beam computed tomography (CBCT) scans using two commercially available software packages. MATERIALS AND METHODS: Ten dry human skulls were subjected to structured light scanning, CBCT scanning, and intra-oral scanning. Two commercially available software packages were used to perform fusion of the intra-oral scans in the CBCT scan to create an accurate virtual head model: IPS CaseDesigner® and OrthoAnalyzer™. The structured light scanner was used as a gold standard and was superimposed on the virtual head models, created by IPS CaseDesigner® and OrthoAnalyzer™, using an Iterative Closest Point algorithm. Differences between the positions of the intra-oral scans obtained with the software packages were recorded and expressed in six degrees of freedom as well as the inter- and intra-observer intra-class correlation coefficient. RESULTS: The tested software packages, IPS CaseDesigner® and OrthoAnalyzer™, showed a high level of accuracy compared to the gold standard. The accuracy was calculated for all six degrees of freedom. It was noticeable that the accuracy in the cranial/caudal direction was the lowest for IPS CaseDesigner® and OrthoAnalyzer™ in both the maxilla and mandible. The inter- and intra-observer intra-class correlation coefficient showed a high level of agreement between the observers. CLINICAL RELEVANCE: IPS CaseDesigner® and OrthoAnalyzer™ are reliable software packages providing an accurate fusion of the intra-oral scan in the CBCT. Both software packages can be used as an accurate fusion tool of the intra-oral scan in the CBCT which provides an accurate basis for 3D virtual planning.

Virtual occlusion in orthognathic surgery.

The aim of this retrospective study was to determine whether a virtually created occlusion is as accurate as a conventionally created occlusion. Seventeen orthognathic patients were included in the study, which was conducted in a university clinic. Plaster cast models were obtained and digitized. Two experienced observers created the conventional (gold standard) and virtual occlusion to assess inter-observer variability. One observer created the conventional and virtual occlusion a second time to assess the intra-observer variability. The criterion for accepting the virtual occlusion was that the difference between the gold standard and the virtual occlusion was not larger than the intra-observer variability for the gold standard. A non-parametric Kruskal-Wallis H test was performed to detect statistically significant differences between the intra- and inter-observer groups for both the conventional and virtual occlusion. No statistically significant differences were found between the different groups. The difference between the conventional and virtual occlusion group was 0.20mm larger than the intra-observer variability of the gold standard. The virtual occlusion tool presented here can be utilized in daily clinical practice and makes the use of physical dental models redundant.

Intraoperative imaging in orbital reconstruction: how does it affect the position of the implant?

Intraoperative imaging enables the surgeon to control the position of the implant during orbital reconstruction. Although it might improve surgical outcome and avoid the need for revision surgery, it may also increase the duration of the operation and the exposure to radiation. The goal of this study was to find out whether intraoperative imaging improves the position of the implant in reconstructions of the orbital floor and medial wall. Two surgeons reconstructed complex orbital fractures in 10 cadavers. After the reconstruction a computed tomographic scan was made to confirm the position of the implant and, if required, to make any adjustments. Scans were repeated until the surgeon was satisfied. The ideal position was ascertained by scans that were obtained before and after creation of the fractures. The position of the implant achieved was compared with that of the ideal position of the implant, and improved significantly for yaw (p=0.04) and roll (p=0.03). A mean of 1.6 scans was required for each reconstruction (maximum n=3). The main reason for alteration was the rotation roll. Intraoperative imaging significantly improves the position of the implant in fractures of the orbital floor and medial wall. The surgeon has quality control of its position during the reconstruction to restore the anatomical boundaries.

Implant-oriented navigation in orbital reconstruction part II: preclinical cadaver study.

In orbital reconstruction, the acquired position of an orbital implant can be evaluated with the aid of intraoperative navigation. Feedback of the navigation system is only obtained after positioning of the implant: the implant's position is not tracked in real time during positioning. The surgeon has to interpret the navigation feedback and translate it to desired adjustments of the implant's position. In a previous study, a real-time implant-oriented navigation approach was introduced and the system's accuracy was evaluated. In this study, this real-time navigation approach was compared to a marker-based navigation approach in a preclinical set-up. Ten cadavers (20 orbital defects) were reconstructed twice, by two surgeons (total: 80 reconstructions). Implant positioning was significantly improved in the real-time implant-oriented approach in terms of roll (2.0° vs. 3.2°, P=0.03), yaw (2.2° vs. 3.4°, P=0.01) and translation (1.3mm vs. 1.8mm, P=0.005). Duration of the real-time navigation procedure was reduced (median 4.5 min vs. 7.5 min). Subjective appreciation of the navigation technique was higher for real-time implant-oriented navigation (mean 7.5 vs. 9.0). Real-time implant-oriented navigation feedback provides real-time, intuitive feedback to the surgeon, which leads to improved implant positioning and shortens duration of the navigation procedure.

Virtual setup in orthodontics: planning and evaluation.

OBJECTIVES: The purpose of this study was to evaluate the clinical accuracy of virtual orthodontic setups by using a new CBCT-based approach. MATERIALS AND METHODS: Ten patients who underwent pre-surgical orthodontics were included in this study. Pre-treatment and pre-surgical cone-beam CT (CBCT) scans and digital dental models were available. The pre-treatment digital dental model was used to create an orthodontic virtual setup. The digital dental models were fused with the corresponding CBCT scans, and the two CBCT scans were aligned using voxel-based matching. Moving each individual tooth from the virtual setup to the final outcome allows the calculation of the accuracy of the virtual setup by using an iterative closest point algorithm. Differences between virtual setup and final outcome were recorded as well as the ICC between two observers. RESULTS: The inter-observer variability showed a high level of agreement between the observers. The largest mean difference between observers was found in the cranial/caudal direction (0.36 ± 0.30 mm) and the roll rotation (1.54 ± 0.98°). Differences between the virtual setup and final outcome were small in the translational direction (0.45 ± 0.48 mm). Rotational mean differences were larger with the pitch of the incisors (0.00 ± 7.97°) and molars (0.01 ± 10.26°) as largest difference. Excessive extrusion of all upper teeth and more anterior movement than planned were seen for both upper and lower arch. Lower molars showed less extrusion. CLINICAL RELEVANCE: The data of this study can be used to obtain more insight in the accuracy and achievability of orthodontic virtual setup. Tooth movement can now be studied in more details which can lead to new insights.

Splintless surgery using patient-specific osteosynthesis in Le Fort I osteotomies: a randomized controlled multi-centre trial.

The accuracy of orthognathic surgery has improved with three-dimensional virtual planning. The translation of the planning to the surgical result is reported to vary by >2mm. The aim of this randomized controlled multi-centre trial was to determine whether the use of splintless patient-specific osteosynthesis can improve the accuracy of maxillary translation. Patients requiring a Le Fort I osteotomy were included in the trial. The intervention group was treated using patient-specific osteosynthesis and the control group with conventional osteosynthesis and splint-based positioning. Fifty-eight patients completed the study protocol, 27 in the patient-specific osteosynthesis group and 31 in the control group. The per protocol median anteroposterior deviation was found to be 1.05mm (interquartile range (IQR) 0.45-2.72mm) in the patient-specific osteosynthesis group and 1.74mm (IQR 1.02-3.02mm) in the control group. The cranial-caudal deviation was 0.87mm (IQR 0.49-1.44mm) and 0.98mm (IQR 0.28-2.10mm), respectively, whereas the left-right translation deviation was 0.46mm (IQR 0.19-0.96mm) in the patient-specific osteosynthesis group and 1.07mm (IQR 0.62-1.55mm) in the control group. The splintless patient-specific osteosynthesis method improves the accuracy of maxillary translations in orthognathic surgery and is clinically relevant for planned anteroposterior translations of more than 3.70mm.

The normal evolution of the cranium in three dimensions.

Insight into the growth and development of the normal newborn cranial shape is essential to monitor cranial development, to detect and diagnose abnormal skull shapes, and for the long-term follow-up of craniosynostosis surgery. The aim of this study was to analyse the growth pattern of the cranial shape of infants during the first years of life using 3D stereophotogrammetry and 3D computed tomography (CT) with advanced 3D evaluation techniques. A large set of 3D photographs (n=199) and CT scans (n=183), taken between ages 0 and 54 months, was collected. Cranial shapes with artefacts and asymmetries were removed. Total volumes and intracranial volumes were obtained, as well as 3D and 2D measurements, including the cranial width, cranial length, cranial index, and suture lengths. Growth maps were created for all modalities to indicate 3D growth over time. For the final analysis, a total of 130 3D photographs, 94 hard tissue CT scans, and 76 soft tissue CT scans were used. 3D and 2D measures, volumes, growth maps, and growth animations were obtained. A non-uniform growth was revealed by the 3D growth maps. This study addresses the need for normative cranial evolution data to monitor healthy cranial development and for detection, follow-up, and treatment planning in craniosynostosis.

Effect of skin tone on the accuracy of hybrid and passive stereophotogrammetry.

BACKGROUND: Three-dimensional (3D) surface images acquired from stereophotogrammetry are increasingly being used to plan or evaluate treatment by plastic surgeons. Stereophotogrammetry exists in active, passive, and hybrid forms. Active and hybrid stereophotogrammetry are believed to capture darker surfaces more accurately than passive stereophotogrammetry. The purpose of this study was to investigate whether skin tone has a clinically relevant effect on the accuracy of hybrid and passive stereophotogrammetry. MATERIALS AND METHODS: Seven subjects with different skin tones were recruited. 3D-printed face and breast were spray-painted in six different colors, ranging from white to black. The skin tones and paint colors were objectified by measuring their melanin index. 3D photos of the subjects and 3D prints were acquired with hybrid and passive stereophotogrammetry. These 3D photos were matched with specialized software, and their geometric differences were calculated. RESULTS: None of the 3D photos showed a clinically relevant mean inaccuracy. On the 3D prints, hybrid stereophotogrammetry resulted in a smaller standard deviation of the inaccuracies than passive stereophotogrammetry (0.20 ± 0.06 mm vs. 0.35 ± 0.07 mm, p < 0.001). Passive stereophotogrammetry yielded a correlation between the melanin index of the spray paint colors and the standard deviation of the inaccuracy (Pearson's R = 0.60, p = 0.04). On human subjects, no correlation or difference in standard deviation of the accuracy was found. CONCLUSION: Skin tone does not influence the accuracy of hybrid and passive 3D stereophotogrammetry in a clinically relevant way.

Reliability and accuracy of skin-supported surgical templates for computer-planned craniofacial implant placement, a comparison between surgical templates: With and without bony fixation.

INTRODUCTION: The purpose is to determine the accuracy of guided implant placement in the orbital, nasal, and auricular region using computer-aided designed stereolithographic skin-supported surgical templates with and without bone fixation pins. MATERIALS AND METHODS: Preoperatively, cone-beam CT (CBCT) and multiple detector computed tomography (MDCT) scans were acquired from 10 cadaver heads, followed by virtual planning of implants in the orbital margin, auricular region and nasal floor. Surgical skin-supported templates were digitally designed to allow flapless implant placement. Fixation pins were used for stabilization comprising half of all templates in predetermined bone areas. The accuracy of the surgical templates was validated by comparing the achieved implant location to its virtual planned implant position by calculating the linear and angular deviations. RESULTS: Surgical templates with the use of bone fixation pins produced statistically significant greater implant deviations as compared to the non-fixated surgical templates. CONCLUSION: The results of this study indicate that significant deviation has to be taken into account when placing cranio-maxillofacial implants using skin-supported surgical templates. Surprisingly, the use of bone-fixated pins worsened the accuracy.

Three dimensional maxillary growth modeling in newborns.

OBJECTIVES: The aim of this study was to develop an accurate and intuitive semi-automatic segmentation technique to calculate an average maxillary arch and palatal growth profile for healthy newborns in their first year of life. MATERIALS AND METHODS: Seventy babies born between 1985 and 1988 were included in this study. Each child had five impressions made in the first year after birth that were digitalized. A semi-automatic segmentation tool was developed and used to assess the maxillary dimensions. Finally, random effect models were built to describe the growth and build a simulation population of 10,000 newborns. The segmentation was tested for inter- and intra-observer variability. RESULTS: The Pearson correlation coefficient for each of the variables was between 0.94 and 1.00, indicating high inter-observer agreement. The paired sample t test showed that, except for the tuberosity distance, there were small, but significant differences in the landmark placements between observers. Intra-observer repeatability was high, with Pearson correlation coefficients ranging from 0.87 to 1.00 for all measurements, and the mean differences were not significant. A third or second degree growth curve could be successfully made for each parameter. CONCLUSIONS: These findings indicated this method could be used for objective clinical evaluation of maxillary growth. CLINICAL RELEVANCE: The resulting growth models can be used for growth studies in healthy newborns and for growth and treatment outcome studies in children with cleft lip and palate or other craniofacial anomalies.