Accuracy of Hard Tissue Predictions in Mono- and Bimaxillary Orthognathic Surgery Using 3D Virtual Surgical Planning

Accuracy of Hard Tissue Predictions in Mono- and Bimaxillary Orthognathic Surgery Using 3D Virtual Surgical Planning | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Accuracy of Hard Tissue Predictions in Mono- and Bimaxillary Orthognathic Surgery Using 3D Virtual Surgical Planning Sacha Decho, Konrad Tolksdorf, Christoph-Ludwig Hennig, Stefan Schultze-Mosgau, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8436476/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives The aim of this study was to quantify the accuracy of hard tissue predictions in three-dimensional virtual surgical planning by comparing planned and achieved cephalometric angles. Materials and Methods This retrospective cohort study included 53 patients with dentofacial deformities who underwent bilateral sagittal split osteotomy with (n = 29) or without Le Fort I osteotomy (n = 24). The data set comprised preoperative computed tomography scans of the skull and pre- and postoperative lateral cephalometric radiographs. Initially, two- and three-dimensional preoperative cephalometric analyses were compared to quantify measurement errors. Subsequently, angular parameters planned during three-dimensional virtual surgical planning were compared with those obtained postoperatively via two-dimensional cephalometric analysis. Clinical relevance was defined as a mean deviation greater than 2°. Results Prior to surgical intervention, no significant angular deviations were identified. Postoperatively, five out of seven angular parameters showed mean deviations statistically significant within the predefined threshold (p 0.05). Conclusions No statistically significant differences were observed between two-dimensional and three-dimensional cephalometric assessments. Planned and clinically achieved angular parameters matched to a high degree for maxillary movements, while sufficient accuracy for vertical repositioning of the mandible could not be demonstrated. Clinical Relevance: Virtual surgical planning shows sufficient accuracy for maxillary positioning. For unbiased postoperative evaluation of mandibular positioning, lateral cephalometric radiographs should be obtained after complete remission of swelling and represent a cost-effective, low-radiation alternative to three-dimensional imaging for sagittal and vertical assessment. orthognathic surgery cephalometry virtual surgical planning hard tissue prediction clinical evaluation study Figures Figure 1 INTRODUCTION The high level of accuracy required in skeletal positioning has contributed to the widespread adoption of three-dimensional virtual surgical planning (3D-VSP) in orthognathic surgery. A systematic review of the evidence on hard tissue positioning has been conducted in several publications, including those by Stokbro et al., Alkhayer et al., Tondin et al., Starch-Jensen et al. and Tabchi et al., among others [ 1 – 5 ]. In the studies included by these authors, the accuracy of 3D-simulated hard tissue positioning was assessed through postoperative imaging, primarily using cone-beam computed tomography (CBCT) and conventional cranial computed tomography (CT) [ 6 – 13 ]. Overall, the studies demonstrate a high degree of agreement between the preoperatively planned and the postoperatively achieved jaw positions, with deviations mostly within the clinically acceptable range defined by the authors. However, varying levels of accuracy were reported [ 1 – 5 ]. Stokbro et al. supported the reproducibility and accuracy of VSP when used in combination with CAD/CAM-fabricated surgical splints. However, due to the high variance in study results, the authors emphasized the need for further independent research to validate the reproducibility and accuracy of VSP [ 1 ]. They also raised concerns regarding the routine reliance on CT or CBCT data [ 1 ], which is used for both 3D planning and postoperative validation. Although CBCT involves lower radiation exposure than conventional CT, it still results in 5 times instead of 40 times the effective dose compared to standard lateral cephalometric radiographs (LCRs) [ 14 ]. Furthermore, higher costs represent an additional barrier to its use in clinical practice. While preoperative three-dimensional imaging is indispensable for 3D-VSP, radiation exposure could be minimized postoperatively by favoring conventional radiographs. Given these circumstances, the question arises whether alternative imaging methods, particularly LCR, can provide sufficiently accurate means of postoperative validation of jaw positioning following 3D-VSP. The primary objective of this study was to evaluate the accuracy of virtually planned orthognathic surgeries in patients with skeletal dentofacial deformities based on cephalometric angles in the midsagittal plane. As an initial measure, the comparability of two-dimensional (2D) and three-dimensional (3D) cephalometric analysis was assessed based on our study protocol. Secondly, the accuracy of 3D-VSP in the midsagittal plane was evaluated using predefined cephalometric angles. MATERIAL AND METHODS Study Design This study was designed as a retrospective cohort study at the Department of Oral and Maxillofacial Surgery / Plastic Surgery, University Hospital Jena, Germany. Patients with dentofacial deformities who underwent bilateral sagittal split osteotomy (BSSO) with or without Le Fort I osteotomy between March 2022 and June 2025 were included. Exclusion criteria were age under 18 years, simultaneous genioplasty, omission of parts of the mandible in preoperative LCR due to suboptimal image framing and absence of a postoperative LCR within 30 days after surgery. 3D-VSP and Surgical Procedures Preoperatively, a CT scan of the head and an intraoral 3D surface scan were acquired. Segmentation of independent craniofacial structures and conversion of CT datasets into Standard Triangle Language files (STL files) were performed using Mimics (Materialise NV, Leuven, Belgium). The intraoral scan was processed using OnyxCeph (Image Instruments GmbH, Chemnitz, Germany). A digital 3D model of the dental arcs was created preoperatively in habital occlusion. Subsequently, the upper and lower dental arcs were printed using Composer (Asiga, Sydney, Australia) and repositioned manually, aligning the dental surfaces to the desired postoperative occlusion before another 3D surface scan was performed. The resulting pre- and postoperative dental models, along with the CT datasets, were then imported into the virtual planning software ProPlan/Enlight CMF (Materialise NV, Leuven, Belgium). Since the CT scans were acquired with patients in a supine position and occasionally with partially opened mouths, the initial 3D occlusal relationship had to be reconstructed to ensure maximal intercuspation. To achieve this, the preoperative dental model was aligned with the maxillary CT dataset, followed by mandibular positioning through superimposition based on the dental model. This procedure also facilitated the reduction of dental artifacts, including those caused by fixed orthodontic appliances. 3D cephalometric analysis, virtual osteotomy and jaw repositioning were conducted by the respective surgeon to simulate the desired postoperative outcome. CAD/CAM-fabricated intermaxillary splints were then printed using Composer. The surgical procedures were performed under general anesthesia by various surgeons at the Department of Oral and Maxillofacial Surgery / Plastic Surgery, University Hospital Jena, Germany. In cases of bimaxillary surgery, a maxilla-first approach was employed. A Le Fort I osteotomy was carried out in accordance with the virtual surgical plan. Subsequently, the mandibular condyles were manually guided into centric position and the maxilla was positioned using the intermediate splint. This was followed by a BSSO according to Obwegeser/Dal Pont or Hunsuck/Epker. In patients who solely underwent BSSO, only the latter was performed. Measurements To assess measurement error between 2D and 3D cephalometric analyses, angular measurements were obtained both from the preoperative 3D virtual simulation and the preoperative LCR. A detailed overview of the osseous landmarks utilized is provided in Table 1 . Corresponding angular parameters are presented in Table 2 . Table 1 Definition of dental and osseous cephalometric landmarks Landmark Definition Sella (S) 2D/3D Central point of hypophyseal fossa in the midsagittal plane Nasion (N) 2D/3D Anterior point of the frontonasal suture Basion (Ba) 2D/3D Posterior point on the anterior curvature of the alveolar process of the maxilla in the midsagittal plane Subnasal (A) 2D/3D Posterior point on the anterior curvature of the alveolar process of the maxilla in the midsagittal plane Anterior nasal spine (ANS) 2D/3D Anterior point of the anterior nasal spine Posterior nasal spine (PNS) 2D/3D Posterior point of the palatine spine Supramentale (B) 2D/3D Posterior point on the anterior curvature of the alveolar process of the mandible in the midsagittal plane Pogonion (Pog) 2D/3D Anterior point of the bony chin Mention (Me) 2D/3D Caudal point of the bony chin in the midsagittal plane Caudal tangial point (Tang) 2D Caudal tangential point of the horizontal mandibular ramus at the mandibular angle (TangR) 3D Tangential point of the right mandibular ramus (TangL) 3D Tangential point of the left mandibular ramus Table 2 Definition of angular cephalometric parameters. Relations Angle Definition sagittal SNA 2D/3D Angle between the points S, N and A SNB 2D/3D Angle between the points S, N and B ANB 2D/3D SNA – SNB SNPog 2D/3D Angle between the points S, N and Pog vertical MxP-NS 2D/3D Angle between the lines S-N and ANS-PNS MnP-NS 2D Angle between the lines S-N and Tang-Me 3D Angle between the line S-N and the plane TangL-Me-TangR MxP-MnP 2D Angle between the lines ANS-PNS and Tang-Me 3D Angle between the line ANS-PNS and the plane TangL-Me-TangR In total, seven angular measurements were employed to evaluate skeletal structures in both the maxilla and mandible. A threshold of 2° was defined as cutoff for clinical relevance, in alignment with previously published studies [ 15 , 16 ]. The 2D cephalometric evaluation was conducted using OnyxCeph. In cases where double bone contours were present, the corresponding landmark was placed at the midpoint between the contours. The 3D analysis was performed in ProPlan CMF, using the preoperative virtual simulation in maximal occlusion. Landmarks were identified in the sagittal, frontal and transverse planes of the CT dataset and visually verified using the 3D volumetric rendering. The generation of auxiliary points, reference lines and planes was performed automatically within ProPlan/Enlight CMF. Angular values were computed as projections onto the midsagittal plane. The primary outcome parameters of this study were the angular discrepancies between the planned postoperative 3D simulation and the clinical outcome, as assessed on the postoperative LCRs. For the 3D simulation, landmark relocation and angular recalculation following virtual repositioning were performed automatically by the software. Maxillary parameters were analyzed in the bimaxillary surgery group. For analysis of mandibular-dependent parameters, postoperative LCR of both surgery groups were examined. Cases with insufficient occlusion or incomplete depiction of the mandible in the LCR were excluded from the analysis. Insufficient occlusion was defined as cases, in which the presence of dental contact could be reliably ruled out based on the LCR. The frequently cited threshold for clinical relevance of 2mm and 4° difference between the planned and achieved surgical outcome was established to evaluate jaw positioning in 3D datasets [ 6 , 7 , 9 , 17 , 18 ]. However, its direct transfer to cephalometric analysis did not appear appropriate. As the preoperative comparison, a 2° threshold of clinical significance was adopted for a conservative assessment of the postoperative outcome in this study. Statistics The collected data was stored locally in pseudonymized form in accordance with the data protection regulations for the processing of personal data outlined in Article 5 of the General Data Protection Regulation (GDPR). The data was then transferred to SPSS Statistics 30.0 (IBM, Armonk, USA) for statistical analysis. For descriptive analysis, extreme values, medians, arithmetic means with corresponding standard deviations and 95%-confidence intervals were reported. For visual illustration, Bland-Altman plots were created. Assumption of normality was tested using histograms as well as the Shapiro-Wilk test. To assess accuracy, the mean angular 2D-3D difference was calculated, while the corresponding standard deviation served as a measure of precision. Comparisons between preoperative 2D and 3D parameters were performed using the Wilcoxon signed-rank test for dependent samples. To evaluate subgroup differences in mandible-dependent postoperative parameters between BSSO with concomitant Le Fort I osteotomy and BSSO alone, independent samples t-tests were performed. Prior to each comparison, Levene’s test was conducted to assess the assumption of homogeneity of variances. 2D-3D differences and the threshold of clinical significance was compared using paired t-test or Wilcoxon signed-rank test. A retrospective power analysis was conducted using G*Power (version 3.1.9.7, University of Düsseldorf, Germany) is shown in Supplementary Table 1 . Statistical significance was defined as p < 0.05. RESULTS Demographics Of the 53 patients included in this study, 29 underwent bimaxillary osteotomy, while 24 received isolated BSSO procedures. The cohort consisted of 25 (47.2%) male and 28 (52.8%) female patients. The age of participants at the time of surgery ranged from 20 to 59 years, with a mean age of 31.6 ± 9.5 years. Mandibula-dependent postoperative parameters were analyzed in 41 patients. The patient inclusion process is illustrated in Fig. 1 , and detailed patient characteristics are provided in Supplementary Table 2 . Comparing 2D and 3D Cephalometry Table 3 presents extreme values, medians, arithmetic means with corresponding standard deviations, mean 2D-3D differences with corresponding 95%-confidence interval and p-values of the preoperative 2D and 3D angular measurements. Table 3 Preoperative angular parameters in degrees [°] Angle Minimum Maximum Median Mean [95%-CI] SD p-value¹ SNA 2D 73.7 91.6 82.4 82.528 3.915 3D 73.8 91.2 82.5 82.464 3.948 2D-3D -0.3 0.8 0.1 0.064 [0.002; 0.127] 0.227 0.066 SNB 2D 68.4 94.9 81.3 81.143 5.653 3D 68.4 95.1 81.5 81.225 5.673 2D-3D -1.9 0.9 -0.1 -0.081 [-0.196; 0.033] 0.414 0,210 ANB 2D -7.5 11.4 0.6 1.381 4.780 3D -7.7 11.5 0.0 1.247 4.849 2D-3D -0.5 1.7 0.1 0.134 [0.010; 0.258] 0.449 0.079 SNPog 2D 68.3 95.2 83.2 82.655 5.822 3D 68.4 95.4 83.4 82.738 5,785 2D-3D -2.1 1.4 -0.1 -0.083 [-0.239; 0.073] 0.568 0.167 MxP-NS 2D -2.1 13.2 7.6 7,215 3.692 3D -2.4 13.6 8.0 7.242 3.785 2D-3D -0.9 1.1 -0.1 -0.026 [-0.124; 0.071] 0.354 0.353 MnP-NS 2D 11.2 51.3 29.7 29.353 7.560 3D 10.7 51.0 29.3 29.181 7.563 2D-3D -0.8 3.7 0.1 0.172 [-0.031; 0.374] 0.735 0.227 MxP-MnP 2D 2.6 41.1 22.1 22.126 7.697 3D 1.8 40.7 21.7 21.972 7.842 2D-3D -1.2 3.7 0.0 0.155 [-0.048; 0.357] 0.736 0.277 Sample size = 53. CI = Confidence interval. SD = Standard deviation. ¹ Statistical analysis was conducted using Wilcoxon signed-rank test; two-sided p-values are reported. Statistical significance was set at a level of α = 0.05. Means, standard deviations, confidence intervals and p-values were rounded to three decimal places. No statistically significant differences were observed between 2D and 3D measurements for any of the assessed angular parameters. None of the seven angular parameters assessed showed a mean deviation between 2D and 3D measurements exceeding the predefined threshold for clinical relevance. The deviations ranged from − 0.083° (± 0.568°) to + 0.172° (± 0.735°). Notably, for the mandibular-dependent angles SNPog, MnP-NS and MxP-MnP, individual deviations exceeding the threshold for clinical relevance were observed. Bland-Altman plots ( Supplementary Figs. 1–10 ) are provided for visual illustration. Accuracy and Precision of 3D-VSP The subgroup analysis comparing BSSO with and without concomitant Le Fort I osteotomy revealed no statistically significant differences in the evaluated mandible-dependent parameters (p > 0.05; Supplementary Table 3 ). Consequently, both subgroups were analyzed as a single cohort in the subsequent evaluations. Table 4 presents extreme values, medians, arithmetic means with corresponding standard deviations, mean 2D-3D differences with corresponding 95%-confidence interval and p-values of the postoperative 2D and 3D angular measurements. Table 4 Postoperative angular parameters in degrees [°] p-value testing Angle N Minimum Maximum Median Mean [95%-CI] SD -2 + 2 SNA 29 2D 77.4 93.1 84.0 83.745 3.754 3D 77.3 92.9 84.1 83.659 3.793 2D-3D -0.5 0.8 0.1 0.086 [-0.014; 0.187] 0.264 < 0.001¹ < 0.001¹ SNB 41 2D 71.5 91.7 79.5 80.012 4.170 3D 71.3 92.3 81.1 80.732 4.253 2D-3D -2.9 1.4 -0.5 -0.720 [-1.002; -0.437] 0.895 < 0.001² < 0.001² ANB 41 2D -3.4 6.9 3.0 2.841 2.172 3D -3.4 6.1 2.1 2.063 2.284 2D-3D -2.6 2.9 0.6 0.778 [0.464; 1.093] 0.996 < 0.001² < 0.001² SNPog 41 2D 71.2 93.0 81.1 81.212 4.474 3D 71.4 93.5 82.3 82.395 4.582 2D-3D -3.5 1.0 -1.0 -1.183 [-1.543; -0.823] 1.141 < 0.001¹ < 0.001¹ MxP-NS 29 2D 0.5 15.3 9.3 8.852 3.587 3D 0.6 15.5 9.2 8.910 3.536 2D-3D -1.1 0.9 0.0 -0.059 [-0.213; 0.096] -0.407 < 0.001¹ < 0.001¹ MnP-NS 41 2D 18.8 49.2 29.8 30.756 7.092 3D 11.7 49.0 28.8 28.702 7.145 2D-3D -0.5 8.2 0.7 2.054 [1.232; 2.875] 2.602 < 0.001² 0.472² MxP-MnP 41 2D 10.3 37.7 22.9 23.190 7.232 3D 2.8 37.8 22.1 21.176 7.529 2D-3D -0.4 8.3 0.7 2.015 [1.195; 2.834] 2.596 < 0.001² 0.413² N = sample size. CI = Confidence interval. SD = Standard deviation. Statistical analysis was conducted using paired t-test ¹ or Wilcoxon signed-rank test ² for threshold of clinical relevance; one-sided p-values are reported. Statistical significance was set at a level of α = 0.05. Means, standard deviations, confidence intervals and p-values were rounded to three decimal places. While 2D-3D differences in five out of seven evaluated angles were statistically within the predefined threshold (p < 0.05), only two angles exhibited mean differences greater 2°. MnP-NS and MxP-MnP showed mean deviations of + 2.054° (± 2.602°) and + 2.015° (± 2.596°), respectively. The smallest deviations were observed for the maxillary angles SNA and MxP-NS. Overall, deviations ranged from − 1.183° (± 1.141°) to + 2.054° (± 2.602°). Except for SNA and MxP-NS, all angles showed individual deviations exceeding the defined threshold for clinical relevance. DISCUSSION Comparing 2D and 3D Cephalometry As a first step, the comparability of 2D and 3D cephalometric analyses was assessed by comparing LCR and cranial CT scans preoperatively. No statistically significant difference was found in all seven angular parameters examined (Table 3 ). For all angles, the mean differences and their corresponding 95% confidence intervals lay within the predefined threshold of clinical relevance set at 2°. Thus, the observed average deviations can be considered negligible from a clinical perspective. In contrast to the mean values, individual differences may be clinically significant. These findings are largely consistent with those reported by van Vlijmen et al. The authors investigated the measurement accuracy between conventional 2D LCR and CBCT-generated 3D skull models. In their study, statistically significant differences were observed in seven out of ten cephalometric angles. Notably, only MnP-NS showed a mean difference exceeding 2°. The authors attributed this discrepancy to differences between the mandibular plane as determined on LCRs and the 3D mandibular plane as used in the 3D simulation. [ 19 ] In our study, MnP-NS showed no statistically significant mean difference. The 3D angular measurements in our study were conducted in the midsagittal plane, which serves to mitigate potential asymmetries between the left and right sides. This approach aligns conceptually with landmark placement in 2D cephalometry, where, in presence of two bony contours, landmarks are placed at the midpoint between the contours. Yitschaky et al. reported statistically significant differences (p < 0.05) for Sella turcica dependent angles, namely SNA, SNB and MnP-NS [ 20 ]. They attributed these discrepancies to challenges in identifying the Sella turcica on LCRs [ 20 ]. In contrast, our study found that the angles SNA and SNB, along with SNPog and MxP-NS, exhibited the smallest mean deviations of all angles examined. A clinical evaluation based on patient data was performed in the studies conducted by Nalçaci et al. and Zamora et al. [ 21 , 22 ]. Both studies reported mean deviations within our defined threshold of clinical relevance in five out of fourteen [ 21 ] and nine out of ten [ 22 ] angular parameters, respectively. Accuracy and Precision of 3D-VSP The mean angular deviations between the planned and achieved postoperative results were statistically significant within the predefined threshold in five out of seven parameters (Table 4 ). The other two mandibular-dependent parameters showed mean 2D-3D differences close to ± 2°. These findings support the conclusion of Bengtsson et al. In their randomized controlled study, the authors examined the 3D planning accuracy in 57 patients with class III malocclusion. A greater deviation was observed in the mandibular parameters compared to the maxillary parameters. [ 10 ] Tran et al. and Hsu et al. confirmed those findings [ 7 , 12 ]. With a mean linear deviation of 0.79 mm compared to 1.0 mm [ 12 ] and the largest mean squared deviation of 1.0 mm compared to 1.1 mm [ 7 ], maxillary positioning demonstrated greater accuracy than mandibular positioning. In contrast, the results of the study by Stokbro et al. differ. Analyzing 30 patients who underwent bimaxillary surgery, more precise mandibular positioning when compared to the maxilla was achieved. The authors suggested that this difference could be attributed to the surgical approach, with the mandibula-first strategy introducing an additional source of error for subsequent maxilla positioning. [ 8 ] In our study, the postoperative horizontal mandibular angles SNB and SNPog showed a mean overestimation in the 3D-VSP. Riu et al. reported a similar finding in their study [ 23 ]. The authors attributed the more posterior position of the distal mandibular segment partly to intraoperative malpositioning of the mandibular condyles [ 23 ]. According to Shirota et al., when using intermaxillary splints, the accuracy of maxillary positioning also depends on the correct condylar positioning [ 24 ]. Therefore, the high accuracy of the maxillary angles reported in our study does not suggest incorrect intraoperative condylar positioning. Clinically relevant individual deviations were observed in five out of seven angles investigated. For the vertical mandibular-dependent angles MnP-NS and MxP-MnP, maximum deviations exceeded twice the defined clinical relevance threshold. While the accuracy of hard tissue positioning generally yielded satisfactory average results, deviations for individual patients could be quite pronounced. Limitations As a retrospective analysis, this study is subject to data bias. The preoperative LCRs and CT scans were not necessarily obtained at the same time. However, since these were primarily used for the purpose of cephalometric analysis within the framework of 3D-VSP and the patients were in the phase of orthodontic retention, the bias should be considered minimal. A different assessment applies to the postoperative period. Since the mandibula-dependent angles are also influenced by mouth opening and the planned parameters were calculated for maximum intercuspation, a considerable distortion arises in cases of insufficient occlusion. Accordingly, an overestimation of the angles SNB and SNPog as well as an underestimation of the angles ANB, MnP-NS and MxP-MnP in the 3D VSP when compared to the achieved outcome on LCRs were observed. This may be attributable to the short interval between surgery and the acquisition of the postoperative LCR. The median interval was five days. In the presence of significant postoperative swelling, occlusion can be compromised by soft tissue interference. To minimize this bias, the authors excluded a total of ten cases with radiographically confirmed nonocclusion from the analysis of mandibular-dependent parameters. Nevertheless, the presence of sufficient occlusion in the remaining cases cannot be assured. The use of postoperative LCRs has the disadvantage of being 2D. A reduction in radiation dose for the patients is achieved by the loss of the mediolateral dimension. Therefore, only horizontal and vertical relations in the midsagittal plane can be assessed. Given that jaw rotation was also performed as part of the orthognathic surgery, a comprehensive assessment of the postoperative hard tissue outcome is not possible with this imaging modality. A significant jaw rotation also leads to changes in the 3D landmark projection in the horizontal plane, which was not accounted for in this analysis. Finally, differences between the maxillary and mandibular success parameters may also be attributed to the treatment regimen. Specifically, only 29 patients were included for the evaluation of maxillary parameters postoperatively, whereas 41 patients were used for the mandibular-dependent parameters. Bimaxillary surgery was performed using the maxilla-first approach, which introduces an additional source of error for mandibular positioning. CONCLUSION While a high degree of agreement between planned and achieved angular parameters was observed for the maxilla, the mandible showed clinically relevant deviations between preoperative prediction and postoperative outcome. When a high-quality LCR is available, 2D and 3D cephalometric analysis show sufficient agreement. Thus, 2D cephalometry can be reliably employed to evaluate anteroposterior and vertical jaw positioning within the sagittal plane, while significantly reducing radiation exposure and costs compared to three-dimensional imaging. To ensure unbiased evaluation of postoperative mandibular positioning, LCR should be conducted after complete remission of swelling. Further prospective studies are required to evaluate the accuracy of 3D-VSP using Proplan/Enlight CMF software and CAD/CAM-fabricated interocclusional splints and identify potential sources of error in mandibula positioning. Declarations Ethics approval and consent to participate : Following the definition of study objectives and methodology, ethical approval was granted by the Ethics Committee of the Jena University Hospital in accordance with the Declaration of Helsinki and the ICH-GCP (registration number: 2025-3925-Bo-D). To protect patient privacy, we strictly comply with data privacy and protection laws and regulations and have undergone strict anonymization of all patient data during the collection process. Due to the use of de-identified historical medical records in this study and the fact that the study protocol posed no additional risks to participants, the ethics committee waived informed consent. Consent to publish : Not applicable. Funding: Not applicable Conflict of Interest : The authors declare that they have no conflict of interest. Author Contribution Sacha Decho, Christoph-Ludwig Henning and Martin Fischer conceptualized the study, with supervision from Stefan Schultze-Mosgau. Methodology was developed by Sacha Decho and Martin Fischer. Data extraction and verification were carried out by Sacha Decho and Martin Fischer. Formal data analysis and figure generation were performed by Sacha Decho, with input from Konrad Tolksdorf, Christoph-Ludwig Hennig, Stefan Schultze-Mosgau and Martin Fischer. Sacha Decho drafted the initial manuscript; Konrad Tolksdorf, Christoph-Ludwig Hennig, Stefan Schultze-Mosgau and Martin Fischer critically revised and edited subsequent versions. Martin Fischer served as senior author. All authors had full access to the data, reviewed and approved the final manuscript, and agreed to its submission for publication. Acknowledgement Claudia Fischer, Institute of Medical Statistic, Computer and Data Science, Jena, Germany, provided advisory support for the statistical analysis. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Stokbro K, Aagaard E, Torkov P, Bell RB, Thygesen T (2014) Virtual planning in orthognathic surgery. Int J Oral Maxillofac Surg 43(8):957–965. https://doi.org/10.1016/j.ijom.2014.03.011 Alkhayer A, Piffkó J, Lippold C, Segatto E (2020) Accuracy of virtual planning in orthognathic surgery: a systematic review. 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Am J Orthod Dentofac Orthop 133(5):640. https://doi.org/10.1016/j.ajodo.2007.11.019 . .e1-5 McIntyre GT, Mossey PA (2002) The craniofacial morphology of the parents of children with orofacial clefting: a systematic review of cephalometric studies. J Orthod 29(1):23–29. https://doi.org/10.1093/ortho/29.1.23 Shaw K, McIntyre G, Mossey P, Menhinick A, Thomson D (2013) Validation of conventional 2D lateral cephalometry using 3D cone beam CT. J Orthod 40(1):22–28. https://doi.org/10.1179/1465313312Y.0000000009 Li Y, Jiang Y, Zhang N, Xu R, Hu J, Zhu S (2015) Clinical feasibility and efficacy of using virtual surgical planning in bimaxillary orthognathic surgery without intermediate splint. J Craniofac Surg 26(2):501–505. https://doi.org/10.1097/SCS.0000000000001530 Shaheen E, Shujaat S, Saeed T, Jacobs R, Politis C (2019) Three-dimensional planning accuracy and follow-up protocol in orthognathic surgery: a validation study. Int J Oral Maxillofac Surg 48(1):71–76. https://doi.org/10.1016/j.ijom.2018.07.011 van Vlijmen OJC, Maal T, Bergé SJ, Bronkhorst EM, Katsaros C, Kuijpers-Jagtman AM (2010) A comparison between 2D and 3D cephalometry on CBCT scans of human skulls. Int J Oral Maxillofac Surg 39(2):156–160. https://doi.org/10.1016/j.ijom.2009.11.017 Yitschaky O, Redlich M, Abed Y, Faerman M, Casap N, Hiller N (2011) Comparison of common hard tissue cephalometric measurements between computed tomography 3D reconstruction and conventional 2D cephalometric images. Angle Orthod 81(1):11–16. https://doi.org/10.2319/031710-157.1 Nalçaci R, Oztürk F, Sökücü O (2010) A comparison of two-dimensional radiography and three-dimensional computed tomography in angular cephalometric measurements. Dentomaxillofac Radiol 39(2):100–106. https://doi.org/10.1259/dmfr/82724776 Zamora N, Llamas JM, Cibrián R, Gandia JL, Paredes V (2011) Cephalometric measurements from 3D reconstructed images compared with conventional 2D images. Angle Orthod 81(5):856–864. https://doi.org/10.2319/121210-717.1 de Riu G, Virdis PI, Meloni SM, Lumbau A, Vaira LA (2018) Accuracy of computer-assisted orthognathic surgery. J Craniomaxillofac Surg 46(2):293–298. https://doi.org/10.1016/j.jcms.2017.11.023 Shirota T, Shiogama S, Asama Y, Tanaka M, Kurihara Y, Ogura H et al (2019) CAD/CAM splint and surgical navigation allows accurate maxillary segment positioning in Le Fort I osteotomy. Heliyon 5(7):e02123. https://doi.org/10.1016/j.heliyon.2019.e02123 Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":15571,"visible":true,"origin":"","legend":"\u003cp\u003eShows the process and criteria for patient selection\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8436476/v1/2a73dede552d35b3870b09a2.png"},{"id":103564101,"identity":"bc5e901b-99f6-4ac1-ab35-b1343e39ffd4","added_by":"auto","created_at":"2026-02-27 06:41:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":953365,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8436476/v1/6d9e740a-4d1d-4ee4-b4b8-c2b5e401b3a3.pdf"},{"id":100127121,"identity":"c23eb04b-6a09-438b-bb7f-dd4d0ca0660c","added_by":"auto","created_at":"2026-01-13 09:26:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":165676,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiguresandTablesCOI.docx","url":"https://assets-eu.researchsquare.com/files/rs-8436476/v1/1609798a8e3c42cbdf8b7cd6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Accuracy of Hard Tissue Predictions in Mono- and Bimaxillary Orthognathic Surgery Using 3D Virtual Surgical Planning","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe high level of accuracy required in skeletal positioning has contributed to the widespread adoption of three-dimensional virtual surgical planning (3D-VSP) in orthognathic surgery. A systematic review of the evidence on hard tissue positioning has been conducted in several publications, including those by Stokbro et al., Alkhayer et al., Tondin et al., Starch-Jensen et al. and Tabchi et al., among others [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the studies included by these authors, the accuracy of 3D-simulated hard tissue positioning was assessed through postoperative imaging, primarily using cone-beam computed tomography (CBCT) and conventional cranial computed tomography (CT) [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the studies demonstrate a high degree of agreement between the preoperatively planned and the postoperatively achieved jaw positions, with deviations mostly within the clinically acceptable range defined by the authors. However, varying levels of accuracy were reported [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStokbro et al. supported the reproducibility and accuracy of VSP when used in combination with CAD/CAM-fabricated surgical splints. However, due to the high variance in study results, the authors emphasized the need for further independent research to validate the reproducibility and accuracy of VSP [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThey also raised concerns regarding the routine reliance on CT or CBCT data [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], which is used for both 3D planning and postoperative validation. Although CBCT involves lower radiation exposure than conventional CT, it still results in 5 times instead of 40 times the effective dose compared to standard lateral cephalometric radiographs (LCRs) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, higher costs represent an additional barrier to its use in clinical practice.\u003c/p\u003e \u003cp\u003eWhile preoperative three-dimensional imaging is indispensable for 3D-VSP, radiation exposure could be minimized postoperatively by favoring conventional radiographs. Given these circumstances, the question arises whether alternative imaging methods, particularly LCR, can provide sufficiently accurate means of postoperative validation of jaw positioning following 3D-VSP.\u003c/p\u003e \u003cp\u003eThe primary objective of this study was to evaluate the accuracy of virtually planned orthognathic surgeries in patients with skeletal dentofacial deformities based on cephalometric angles in the midsagittal plane. As an initial measure, the comparability of two-dimensional (2D) and three-dimensional (3D) cephalometric analysis was assessed based on our study protocol. Secondly, the accuracy of 3D-VSP in the midsagittal plane was evaluated using predefined cephalometric angles.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003e This study was designed as a retrospective cohort study at the Department of Oral and Maxillofacial Surgery / Plastic Surgery, University Hospital Jena, Germany. Patients with dentofacial deformities who underwent bilateral sagittal split osteotomy (BSSO) with or without Le Fort I osteotomy between March 2022 and June 2025 were included. Exclusion criteria were age under 18 years, simultaneous genioplasty, omission of parts of the mandible in preoperative LCR due to suboptimal image framing and absence of a postoperative LCR within 30 days after surgery.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e3D-VSP and Surgical Procedures\u003c/span\u003e \u003c/p\u003e \u003cp\u003ePreoperatively, a CT scan of the head and an intraoral 3D surface scan were acquired. Segmentation of independent craniofacial structures and conversion of CT datasets into Standard Triangle Language files (STL files) were performed using Mimics (Materialise NV, Leuven, Belgium). The intraoral scan was processed using OnyxCeph (Image Instruments GmbH, Chemnitz, Germany).\u003c/p\u003e \u003cp\u003eA digital 3D model of the dental arcs was created preoperatively in habital occlusion. Subsequently, the upper and lower dental arcs were printed using Composer (Asiga, Sydney, Australia) and repositioned manually, aligning the dental surfaces to the desired postoperative occlusion before another 3D surface scan was performed. The resulting pre- and postoperative dental models, along with the CT datasets, were then imported into the virtual planning software ProPlan/Enlight CMF (Materialise NV, Leuven, Belgium). Since the CT scans were acquired with patients in a supine position and occasionally with partially opened mouths, the initial 3D occlusal relationship had to be reconstructed to ensure maximal intercuspation. To achieve this, the preoperative dental model was aligned with the maxillary CT dataset, followed by mandibular positioning through superimposition based on the dental model. This procedure also facilitated the reduction of dental artifacts, including those caused by fixed orthodontic appliances. 3D cephalometric analysis, virtual osteotomy and jaw repositioning were conducted by the respective surgeon to simulate the desired postoperative outcome. CAD/CAM-fabricated intermaxillary splints were then printed using Composer.\u003c/p\u003e \u003cp\u003eThe surgical procedures were performed under general anesthesia by various surgeons at the Department of Oral and Maxillofacial Surgery / Plastic Surgery, University Hospital Jena, Germany. In cases of bimaxillary surgery, a maxilla-first approach was employed. A Le Fort I osteotomy was carried out in accordance with the virtual surgical plan. Subsequently, the mandibular condyles were manually guided into centric position and the maxilla was positioned using the intermediate splint. This was followed by a BSSO according to Obwegeser/Dal Pont or Hunsuck/Epker. In patients who solely underwent BSSO, only the latter was performed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003eTo assess measurement error between 2D and 3D cephalometric analyses, angular measurements were obtained both from the preoperative 3D virtual simulation and the preoperative LCR. A detailed overview of the osseous landmarks utilized is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Corresponding angular parameters are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDefinition of dental and osseous cephalometric landmarks\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLandmark\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSella\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(S)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCentral point of hypophyseal fossa in the midsagittal plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterior point of the frontonasal suture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Ba)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePosterior point on the anterior curvature of the alveolar process of the maxilla in the midsagittal plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubnasal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePosterior point on the anterior curvature of the alveolar process of the maxilla in the midsagittal plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior nasal spine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(ANS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterior point of the anterior nasal spine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior nasal spine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(PNS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePosterior point of the palatine spine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupramentale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePosterior point on the anterior curvature of the alveolar process of the mandible in the midsagittal plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePogonion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Pog)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterior point of the bony chin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Me)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCaudal point of the bony chin in the midsagittal plane\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaudal tangial point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Tang)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCaudal tangential point of the horizontal mandibular ramus at the mandibular angle\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(TangR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTangential point of the right mandibular ramus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(TangL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTangential point of the left mandibular ramus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDefinition of angular cephalometric parameters.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAngle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esagittal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the points S, N and A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSNB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the points S, N and B\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eANB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSNA \u0026ndash; SNB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSNPog\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the points S, N and Pog\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evertical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMxP-NS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D/3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the lines S-N and ANS-PNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMnP-NS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the lines S-N and Tang-Me\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the line S-N and the plane TangL-Me-TangR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMxP-MnP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the lines ANS-PNS and Tang-Me\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAngle between the line ANS-PNS and the plane TangL-Me-TangR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn total, seven angular measurements were employed to evaluate skeletal structures in both the maxilla and mandible. A threshold of 2\u0026deg; was defined as cutoff for clinical relevance, in alignment with previously published studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe 2D cephalometric evaluation was conducted using OnyxCeph. In cases where double bone contours were present, the corresponding landmark was placed at the midpoint between the contours. The 3D analysis was performed in ProPlan CMF, using the preoperative virtual simulation in maximal occlusion. Landmarks were identified in the sagittal, frontal and transverse planes of the CT dataset and visually verified using the 3D volumetric rendering. The generation of auxiliary points, reference lines and planes was performed automatically within ProPlan/Enlight CMF. Angular values were computed as projections onto the midsagittal plane.\u003c/p\u003e \u003cp\u003eThe primary outcome parameters of this study were the angular discrepancies between the planned postoperative 3D simulation and the clinical outcome, as assessed on the postoperative LCRs. For the 3D simulation, landmark relocation and angular recalculation following virtual repositioning were performed automatically by the software. Maxillary parameters were analyzed in the bimaxillary surgery group. For analysis of mandibular-dependent parameters, postoperative LCR of both surgery groups were examined. Cases with insufficient occlusion or incomplete depiction of the mandible in the LCR were excluded from the analysis. Insufficient occlusion was defined as cases, in which the presence of dental contact could be reliably ruled out based on the LCR.\u003c/p\u003e \u003cp\u003eThe frequently cited threshold for clinical relevance of 2mm and 4\u0026deg; difference between the planned and achieved surgical outcome was established to evaluate jaw positioning in 3D datasets [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, its direct transfer to cephalometric analysis did not appear appropriate. As the preoperative comparison, a 2\u0026deg; threshold of clinical significance was adopted for a conservative assessment of the postoperative outcome in this study.\u003c/p\u003e\n\u003ch3\u003eStatistics\u003c/h3\u003e\n\u003cp\u003eThe collected data was stored locally in pseudonymized form in accordance with the data protection regulations for the processing of personal data outlined in Article 5 of the General Data Protection Regulation (GDPR). The data was then transferred to SPSS Statistics 30.0 (IBM, Armonk, USA) for statistical analysis. For descriptive analysis, extreme values, medians, arithmetic means with corresponding standard deviations and 95%-confidence intervals were reported. For visual illustration, Bland-Altman plots were created. Assumption of normality was tested using histograms as well as the Shapiro-Wilk test. To assess accuracy, the mean angular 2D-3D difference was calculated, while the corresponding standard deviation served as a measure of precision. Comparisons between preoperative 2D and 3D parameters were performed using the Wilcoxon signed-rank test for dependent samples. To evaluate subgroup differences in mandible-dependent postoperative parameters between BSSO with concomitant Le Fort I osteotomy and BSSO alone, independent samples t-tests were performed. Prior to each comparison, Levene\u0026rsquo;s test was conducted to assess the assumption of homogeneity of variances. 2D-3D differences and the threshold of clinical significance was compared using paired t-test or Wilcoxon signed-rank test. A retrospective power analysis was conducted using G*Power (version 3.1.9.7, University of D\u0026uuml;sseldorf, Germany) is shown in \u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eOf the 53 patients included in this study, 29 underwent bimaxillary osteotomy, while 24 received isolated BSSO procedures. The cohort consisted of 25 (47.2%) male and 28 (52.8%) female patients. The age of participants at the time of surgery ranged from 20 to 59 years, with a mean age of 31.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5 years. Mandibula-dependent postoperative parameters were analyzed in 41 patients. The patient inclusion process is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and detailed patient characteristics are provided in \u003cb\u003eSupplementary Table\u0026nbsp;2\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eComparing 2D and 3D Cephalometry\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents extreme values, medians, arithmetic means with corresponding standard deviations, mean 2D-3D differences with corresponding 95%-confidence interval and p-values of the preoperative 2D and 3D angular measurements.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative angular parameters in degrees [\u0026deg;]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAngle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean [95%-CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u0026sup1;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82.528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82.464\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.064 [0.002; 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0.258]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.449\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSNPog\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82.655\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.822\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82.738\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5,785\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.083 [-0.239; 0.073]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMxP-NS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7,215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.692\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.785\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.026 [-0.124; 0.071]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMnP-NS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.172 [-0.031; 0.374]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMxP-MnP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.972\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.842\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.155 [-0.048; 0.357]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eSample size\u0026thinsp;=\u0026thinsp;53. CI\u0026thinsp;=\u0026thinsp;Confidence interval. SD\u0026thinsp;=\u0026thinsp;Standard deviation. \u0026sup1; Statistical analysis was conducted using Wilcoxon signed-rank test; two-sided p-values are reported. Statistical significance was set at a level of α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eMeans, standard deviations, confidence intervals and p-values were rounded to three decimal places.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo statistically significant differences were observed between 2D and 3D measurements for any of the assessed angular parameters. None of the seven angular parameters assessed showed a mean deviation between 2D and 3D measurements exceeding the predefined threshold for clinical relevance. The deviations ranged from \u0026minus;\u0026thinsp;0.083\u0026deg; (\u0026plusmn;\u0026thinsp;0.568\u0026deg;) to +\u0026thinsp;0.172\u0026deg; (\u0026plusmn;\u0026thinsp;0.735\u0026deg;). Notably, for the mandibular-dependent angles SNPog, MnP-NS and MxP-MnP, individual deviations exceeding the threshold for clinical relevance were observed. Bland-Altman plots (\u003cb\u003eSupplementary Figs.\u0026nbsp;1\u0026ndash;10\u003c/b\u003e) are provided for visual illustration.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAccuracy and Precision of 3D-VSP\u003c/h3\u003e\n\u003cp\u003eThe subgroup analysis comparing BSSO with and without concomitant Le Fort I osteotomy revealed no statistically significant differences in the evaluated mandible-dependent parameters (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05; \u003cb\u003eSupplementary Table\u0026nbsp;3\u003c/b\u003e). Consequently, both subgroups were analyzed as a single cohort in the subsequent evaluations.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents extreme values, medians, arithmetic means with corresponding standard deviations, mean 2D-3D differences with corresponding 95%-confidence interval and p-values of the postoperative 2D and 3D angular measurements.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative angular parameters in degrees [\u0026deg;]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ep-value testing\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMean [95%-CI]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e83.745\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e83.659\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.086 [-0.014; 0.187]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSNB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e79.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e80.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e81.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e80.732\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.720 [-1.002; -0.437]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.895\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.778 [0.464; 1.093]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSNPog\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e81.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e81.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e82.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e82.395\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.582\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.183 [-1.543; -0.823]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMxP-NS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.587\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.536\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.059 [-0.213; 0.096]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMnP-NS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7.092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e28.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.054 [1.232; 2.875]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.472\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMxP-MnP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e23.190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7.232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e21.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2D-3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.015 [1.195; 2.834]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.413\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;sample size. CI\u0026thinsp;=\u0026thinsp;Confidence interval. SD\u0026thinsp;=\u0026thinsp;Standard deviation. Statistical analysis was conducted using paired t-test \u0026sup1; or Wilcoxon signed-rank test \u0026sup2; for threshold of clinical relevance; one-sided p-values are reported. Statistical significance was set at a level of α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eMeans, standard deviations, confidence intervals and p-values were rounded to three decimal places.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhile 2D-3D differences in five out of seven evaluated angles were statistically within the predefined threshold (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), only two angles exhibited mean differences greater 2\u0026deg;. MnP-NS and MxP-MnP showed mean deviations of +\u0026thinsp;2.054\u0026deg; (\u0026plusmn;\u0026thinsp;2.602\u0026deg;) and +\u0026thinsp;2.015\u0026deg; (\u0026plusmn;\u0026thinsp;2.596\u0026deg;), respectively. The smallest deviations were observed for the maxillary angles SNA and MxP-NS. Overall, deviations ranged from \u0026minus;\u0026thinsp;1.183\u0026deg; (\u0026plusmn;\u0026thinsp;1.141\u0026deg;) to +\u0026thinsp;2.054\u0026deg; (\u0026plusmn;\u0026thinsp;2.602\u0026deg;). Except for SNA and MxP-NS, all angles showed individual deviations exceeding the defined threshold for clinical relevance.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparing 2D and 3D Cephalometry\u003c/h2\u003e \u003cp\u003eAs a first step, the comparability of 2D and 3D cephalometric analyses was assessed by comparing LCR and cranial CT scans preoperatively. No statistically significant difference was found in all seven angular parameters examined (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). For all angles, the mean differences and their corresponding 95% confidence intervals lay within the predefined threshold of clinical relevance set at 2\u0026deg;. Thus, the observed average deviations can be considered negligible from a clinical perspective. In contrast to the mean values, individual differences may be clinically significant.\u003c/p\u003e \u003cp\u003eThese findings are largely consistent with those reported by van Vlijmen et al. The authors investigated the measurement accuracy between conventional 2D LCR and CBCT-generated 3D skull models. In their study, statistically significant differences were observed in seven out of ten cephalometric angles. Notably, only MnP-NS showed a mean difference exceeding 2\u0026deg;. The authors attributed this discrepancy to differences between the mandibular plane as determined on LCRs and the 3D mandibular plane as used in the 3D simulation. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn our study, MnP-NS showed no statistically significant mean difference. The 3D angular measurements in our study were conducted in the midsagittal plane, which serves to mitigate potential asymmetries between the left and right sides. This approach aligns conceptually with landmark placement in 2D cephalometry, where, in presence of two bony contours, landmarks are placed at the midpoint between the contours.\u003c/p\u003e \u003cp\u003eYitschaky et al. reported statistically significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) for Sella turcica dependent angles, namely SNA, SNB and MnP-NS [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. They attributed these discrepancies to challenges in identifying the Sella turcica on LCRs [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In contrast, our study found that the angles SNA and SNB, along with SNPog and MxP-NS, exhibited the smallest mean deviations of all angles examined.\u003c/p\u003e \u003cp\u003eA clinical evaluation based on patient data was performed in the studies conducted by Nal\u0026ccedil;aci et al. and Zamora et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Both studies reported mean deviations within our defined threshold of clinical relevance in five out of fourteen [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and nine out of ten [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] angular parameters, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAccuracy and Precision of 3D-VSP\u003c/h2\u003e \u003cp\u003eThe mean angular deviations between the planned and achieved postoperative results were statistically significant within the predefined threshold in five out of seven parameters (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The other two mandibular-dependent parameters showed mean 2D-3D differences close to \u0026plusmn;\u0026thinsp;2\u0026deg;.\u003c/p\u003e \u003cp\u003eThese findings support the conclusion of Bengtsson et al. In their randomized controlled study, the authors examined the 3D planning accuracy in 57 patients with class III malocclusion. A greater deviation was observed in the mandibular parameters compared to the maxillary parameters. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTran et al. and Hsu et al. confirmed those findings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. With a mean linear deviation of 0.79 mm compared to 1.0 mm [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the largest mean squared deviation of 1.0 mm compared to 1.1 mm [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], maxillary positioning demonstrated greater accuracy than mandibular positioning.\u003c/p\u003e \u003cp\u003eIn contrast, the results of the study by Stokbro et al. differ. Analyzing 30 patients who underwent bimaxillary surgery, more precise mandibular positioning when compared to the maxilla was achieved. The authors suggested that this difference could be attributed to the surgical approach, with the mandibula-first strategy introducing an additional source of error for subsequent maxilla positioning. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn our study, the postoperative horizontal mandibular angles SNB and SNPog showed a mean overestimation in the 3D-VSP. Riu et al. reported a similar finding in their study [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The authors attributed the more posterior position of the distal mandibular segment partly to intraoperative malpositioning of the mandibular condyles [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. According to Shirota et al., when using intermaxillary splints, the accuracy of maxillary positioning also depends on the correct condylar positioning [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, the high accuracy of the maxillary angles reported in our study does not suggest incorrect intraoperative condylar positioning.\u003c/p\u003e \u003cp\u003eClinically relevant individual deviations were observed in five out of seven angles investigated. For the vertical mandibular-dependent angles MnP-NS and MxP-MnP, maximum deviations exceeded twice the defined clinical relevance threshold. While the accuracy of hard tissue positioning generally yielded satisfactory average results, deviations for individual patients could be quite pronounced.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAs a retrospective analysis, this study is subject to data bias. The preoperative LCRs and CT scans were not necessarily obtained at the same time. However, since these were primarily used for the purpose of cephalometric analysis within the framework of 3D-VSP and the patients were in the phase of orthodontic retention, the bias should be considered minimal. A different assessment applies to the postoperative period. Since the mandibula-dependent angles are also influenced by mouth opening and the planned parameters were calculated for maximum intercuspation, a considerable distortion arises in cases of insufficient occlusion. Accordingly, an overestimation of the angles SNB and SNPog as well as an underestimation of the angles ANB, MnP-NS and MxP-MnP in the 3D VSP when compared to the achieved outcome on LCRs were observed. This may be attributable to the short interval between surgery and the acquisition of the postoperative LCR. The median interval was five days. In the presence of significant postoperative swelling, occlusion can be compromised by soft tissue interference. To minimize this bias, the authors excluded a total of ten cases with radiographically confirmed nonocclusion from the analysis of mandibular-dependent parameters. Nevertheless, the presence of sufficient occlusion in the remaining cases cannot be assured.\u003c/p\u003e \u003cp\u003eThe use of postoperative LCRs has the disadvantage of being 2D. A reduction in radiation dose for the patients is achieved by the loss of the mediolateral dimension. Therefore, only horizontal and vertical relations in the midsagittal plane can be assessed. Given that jaw rotation was also performed as part of the orthognathic surgery, a comprehensive assessment of the postoperative hard tissue outcome is not possible with this imaging modality. A significant jaw rotation also leads to changes in the 3D landmark projection in the horizontal plane, which was not accounted for in this analysis.\u003c/p\u003e \u003cp\u003eFinally, differences between the maxillary and mandibular success parameters may also be attributed to the treatment regimen. Specifically, only 29 patients were included for the evaluation of maxillary parameters postoperatively, whereas 41 patients were used for the mandibular-dependent parameters. Bimaxillary surgery was performed using the maxilla-first approach, which introduces an additional source of error for mandibular positioning.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWhile a high degree of agreement between planned and achieved angular parameters was observed for the maxilla, the mandible showed clinically relevant deviations between preoperative prediction and postoperative outcome. When a high-quality LCR is available, 2D and 3D cephalometric analysis show sufficient agreement. Thus, 2D cephalometry can be reliably employed to evaluate anteroposterior and vertical jaw positioning within the sagittal plane, while significantly reducing radiation exposure and costs compared to three-dimensional imaging. To ensure unbiased evaluation of postoperative mandibular positioning, LCR should be conducted after complete remission of swelling.\u003c/p\u003e \u003cp\u003eFurther prospective studies are required to evaluate the accuracy of 3D-VSP using Proplan/Enlight CMF software and CAD/CAM-fabricated interocclusional splints and identify potential sources of error in mandibula positioning.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEthics approval and consent to participate\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e Following the definition of study objectives and methodology, ethical approval was granted by the Ethics Committee of the Jena University Hospital in accordance with the Declaration of Helsinki and the ICH-GCP (registration number: 2025-3925-Bo-D). To protect patient privacy, we strictly comply with data privacy and protection laws and regulations and have undergone strict anonymization of all patient data during the collection process. Due to the use of de-identified historical medical records in this study and the fact that the study protocol posed no additional risks to participants, the ethics committee waived informed consent.\u003c/p\u003e \u003ch2\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eConsent to publish\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eConflict of Interest\u003c/span\u003e: The authors declare that they have no conflict of interest.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSacha Decho, Christoph-Ludwig Henning and Martin Fischer conceptualized the study, with supervision from Stefan Schultze-Mosgau. Methodology was developed by Sacha Decho and Martin Fischer. Data extraction and verification were carried out by Sacha Decho and Martin Fischer. Formal data analysis and figure generation were performed by Sacha Decho, with input from Konrad Tolksdorf, Christoph-Ludwig Hennig, Stefan Schultze-Mosgau and Martin Fischer. Sacha Decho drafted the initial manuscript; Konrad Tolksdorf, Christoph-Ludwig Hennig, Stefan Schultze-Mosgau and Martin Fischer critically revised and edited subsequent versions. Martin Fischer served as senior author. All authors had full access to the data, reviewed and approved the final manuscript, and agreed to its submission for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eClaudia Fischer, Institute of Medical Statistic, Computer and Data Science, Jena, Germany, provided advisory support for the statistical analysis.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStokbro K, Aagaard E, Torkov P, Bell RB, Thygesen T (2014) Virtual planning in orthognathic surgery. 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Heliyon 5(7):e02123. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.heliyon.2019.e02123\u003c/span\u003e\u003cspan address=\"10.1016/j.heliyon.2019.e02123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"orthognathic surgery, cephalometry, virtual surgical planning, hard tissue prediction, clinical evaluation study","lastPublishedDoi":"10.21203/rs.3.rs-8436476/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8436476/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe aim of this study was to quantify the accuracy of hard tissue predictions in three-dimensional virtual surgical planning by comparing planned and achieved cephalometric angles.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study included 53 patients with dentofacial deformities who underwent bilateral sagittal split osteotomy with (n\u0026thinsp;=\u0026thinsp;29) or without Le Fort I osteotomy (n\u0026thinsp;=\u0026thinsp;24). The data set comprised preoperative computed tomography scans of the skull and pre- and postoperative lateral cephalometric radiographs. Initially, two- and three-dimensional preoperative cephalometric analyses were compared to quantify measurement errors. Subsequently, angular parameters planned during three-dimensional virtual surgical planning were compared with those obtained postoperatively via two-dimensional cephalometric analysis. Clinical relevance was defined as a mean deviation greater than 2\u0026deg;.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePrior to surgical intervention, no significant angular deviations were identified. Postoperatively, five out of seven angular parameters showed mean deviations statistically significant within the predefined threshold (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For MnP-NS and MxP-MnP, mean deviations exceeding 2\u0026deg; were shown (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eNo statistically significant differences were observed between two-dimensional and three-dimensional cephalometric assessments. Planned and clinically achieved angular parameters matched to a high degree for maxillary movements, while sufficient accuracy for vertical repositioning of the mandible could not be demonstrated.\u003c/p\u003e\u003ch2\u003eClinical Relevance:\u003c/h2\u003e \u003cp\u003eVirtual surgical planning shows sufficient accuracy for maxillary positioning. For unbiased postoperative evaluation of mandibular positioning, lateral cephalometric radiographs should be obtained after complete remission of swelling and represent a cost-effective, low-radiation alternative to three-dimensional imaging for sagittal and vertical assessment.\u003c/p\u003e","manuscriptTitle":"Accuracy of Hard Tissue Predictions in Mono- and Bimaxillary Orthognathic Surgery Using 3D Virtual Surgical Planning","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 09:26:50","doi":"10.21203/rs.3.rs-8436476/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"61d37ac8-97c8-4ffc-9a11-814140d69251","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T06:40:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-13 09:26:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8436476","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8436476","identity":"rs-8436476","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}