Leveraging a 3D Average Skeletofacial Model of Leptoprosopic Facial Type as a Template for Computer-Assisted Orthognathic Surgery Planning

Leveraging a 3D Average Skeletofacial Model of Leptoprosopic Facial Type as a Template for Computer-Assisted Orthognathic Surgery 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 Article Leveraging a 3D Average Skeletofacial Model of Leptoprosopic Facial Type as a Template for Computer-Assisted Orthognathic Surgery Planning Rae-Chia (Erica) Lai, Hsiu-Hsia Lin, Wen-Chung Chiang, Lun-Jou Lo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6910341/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Surgical planning for patients with skeletal Class III malocclusion and leptoprosopic (long) facial characteristics presents unique challenges, especially when striving for optimal facial aesthetics and proportional balance. This study sought to refine traditional surgical planning methods by developing a specialized 3D craniofacial template for individuals with leptoprosopic facial morphology. We constructed this template using 60 skeletal Class I patients with leptoprosopic features, all of whom had not undergone prior orthognathic surgery. The template was then applied in virtual surgical simulations for 30 skeletal Class III patients with similar facial types, guiding the adjustment of anteroposterior, transverse, and vertical skeletal dimensions. Postoperative CBCT scans were compared to the template to assess the alignment of the jaw positions, while patient satisfaction was measured through a structured questionnaire. The findings revealed minimal discrepancies between postoperative outcomes and the template, with jaw position deviations of less than 2 mm in the anteroposterior and transverse planes, and slight increases (1.8–3.6 mm) in the vertical direction. Notably, the patients reported the highest satisfaction with improvements in chin projection, and most also appreciated changes in vertical facial height. Additionally, 63% of patients experienced a reduction in mandibular height following vertical adjustments. In conclusion, the creation of a tailored leptoprosopic skull template offers a valuable tool for improving the accuracy of surgical planning and enhancing aesthetic outcomes for long-face patients, contributing to more precise treatment and better overall results. Health sciences/Diseases Health sciences/Medical research Leptoprosopic facial type Orthognathic surgery Simulation Facial proportion Figures Figure 1 Figure 2 Figure 3 Introduction Treating patients with skeletal Class III malocclusion and leptoprosopic (long) facial types presents a longstanding challenge for both surgeons and orthodontists. Orthognathic surgery (OGS) aims not only to achieve an aesthetic facial profile and optimal dental occlusion but also to restore the proper facial vertical ratio and maintain natural facial proportions [ 1 ]. During surgery, it is critical to adjust skeletal positions while preserving individualized features, ensuring that these changes align with the underlying skull base morphology. Facial parameters, including those related to facial morphology, have been described using the prosopic index, which is defined as the ratio of morphological facial height to bizygomatic width (facial breadth) multiplied by 100 (N-Me/ZY-ZY %) [ 2 ]. Martin-Saller's scale classifies facial phenotypes into five categories: hyperleptoprosopic, leptoprosopic (long), mesoprosopic (medium), euryprosopic (short), and hypereuryprosopic [ 3 ]. These facial types are influenced by various factors such as sex, ethnicity, genetics, socio-economic status, and nutrition [ 4 – 6 ], with the distribution of these types varying across different populations and genders [ 7 – 9 ]. For instance, studies have found that the dominant facial type in Northern Iran is mesoprosopic, while the leptoprosopic face is most common among the Chinese population [ 10 ]. Moreover, research indicates a significant correlation between facial type and skull base morphology. Specifically, dolichocephalic skulls tend to be associated with leptoprosopic (long) faces, characterized by narrow arches and long facial indices. This relationship suggests that vertical facial patterns cannot be arbitrarily altered with OGS [ 7 , 11 ]. Therefore, the surgical approach for long-faced patients must consider their cephalic index, facial index, and vertical ratios, rather than simply attempting to shorten the face. In an effort to improve the efficiency and objectivity of surgical planning, our research team previously developed a three-dimensional (3D) average model based on individuals with medium facial types to serve as a template for surgical simulations and planning [ 12 – 14 ]. This model has been shown to offer comparable accuracy to traditional 3D cephalometric standards and has demonstrated clinical success, leading to high patient satisfaction and reduced preoperative planning time [ 12 , 13 ]. However, applying this medium facial template to long-face patients would compromise the natural vertical proportions and fail to align with the patient’s cranial base morphology. Studies have demonstrated a strong relationship between facial and skull morphology, highlighting the limitations of arbitrarily altering facial vertical patterns with OGS [ 15 ]. To our knowledge, no prior studies have utilized an average 3D template specifically tailored for diagnosing and planning surgery for long-face patients. The aim of this study is to extend our previous work by developing a 3D craniofacial template for individuals with leptoprosopic facial types, providing a more accurate reference for surgical planning. This template will not only optimize aesthetic and functional outcomes but also serve as a diagnostic tool to assist clinicians in adjusting vertical proportions of the upper and lower jaws. Additionally, this method can be used for teaching purposes, helping junior surgeons and orthodontists refine their diagnostic and treatment planning skills, ultimately enhancing the efficiency and effectiveness of their practice. Results The intraobserver variability in landmark identification was minimal, with an average difference of 0.36 mm, ranging from 0.32 mm to 0.43 mm. Pearson correlation coefficients between the investigators' measurements (r = 0.88 to 0.92; all P < 0.05) indicated a strong and statistically significant correlation, confirming that the virtual-guided data collection process was both accurate and consistent (Table 1 ). Table 1 Intraobserver Reproducibility of Landmark Identification in 3D Coordinate System: Assessment of consistency in landmark identification across repeated measurements. Landmark definition Mean difference ± SD (mm) r p-value A point (A) 0.39 ± 0.21 0.89 0.006 U1 incisal tip 0.32 ± 0.19 0.91 0.005 B point (B) 0.43 ± 0.23 0.88 0.008 Pogonion (Pog) 0.37 ± 0.17 0.90 0.007 Menton (Me) 0.33 ± 0.15 0.92 0.004 Mean 0.36 ± 0.19 R, Pearson correlation coefficient, a p-value less than 0.05 is typically considered to be statistically significant. Table 2 summarizes the discrepancies between the postoperative results and the average skull template. The mean differences were analyzed across three anatomical planes: transverse (mediolateral, x-axis), sagittal (anteroposterior, y-axis), and vertical (superoinferior, z-axis). The results showed that the deviations in both the mediolateral and anteroposterior directions were consistently under 2 mm, which is well within the acceptable threshold [ 16 ]. However, the superoinferior direction exhibited slightly larger discrepancies. Specifically, point A showed a discrepancy of 1.89 mm, while other landmarks displayed deviations ranging from 2 mm to 4 mm. This suggests that alignment was generally more accurate along the x-axis and y-axis, with a greater variability observed in the z-axis. Notably, the maxilla (point A: x = 0.9 mm, y = 1.1 mm, z = 1.0 mm) showed the highest degree of alignment among all landmarks. Table 2 Discrepancy Between Postoperative Results and the Average Skull Template: Comparison of positional deviations across key anatomical landmarks. Parameters Mediolateral Anteroposterior Superoinferior p-value A point 1.15 ± 0.95 1.06 ± 1.00 1.89 ± 1.20 0.031 U1 mid 1.68 ± 0.96 1.00 ± 0.88 2.08 ± 1.64 0.000 B point 1.20 ± 0.97 1.35 ± 1.00 3.39 ± 1.98 0.012 Pog 1.40 ± 1.13 1.79 ± 1.36 3.63 ± 3.28 0.004 Me 1.58 ± 1.28 1.77 ± 1.35 3.47 ± 3.14 0.006 Data are in millimeters and are presented as mean ± standard deviation, *p < 0.05. Table 3 presents the overall appearance rating (OAR) and satisfaction with facial aesthetics (SFA). Among the various facial features, the chin received the highest satisfaction scores, while the nose garnered lower ratings. All ratings were above 8 out of 10, indicating a high level of overall satisfaction. The substantial repositioning of the lower jaw following mandibular setback likely contributed to the increased satisfaction with chin positioning. Table 3 Overall Appearance Rating (OAR) and Patient Satisfaction with Facial Aesthetics: Patient-reported outcomes on post-surgical facial appearance. Scale Orthognathic surgery-treated patients Total (n = 30) Male (n = 16) Female (n = 14) Overall appearance rating (0-100) 91.6 ± 6.5 92.7 ± 6.9 90.3 ± 7.4 Facial area satisfaction (0–10) Cheek fullness 8.8.0 ± 0.7 8.8.0 ± 0.8 8.8.0 ± 0.5 Chin 9.3 ± 0.8 9.6 ± 0.7 8.9 ± 1.1 Nose 8.5 ± 0.5 8.3 ± 0.5 8.7 ± 0.8 Lip 8.9 ± 1.0 8.9 ± 1.1 8.9 ± 0.7 Gum show 8.6 ± 1.2 8.4 ± 1.3 8.8 ± 1.3 Dental alignment 8.8 ± 1.1 8.9 ± 1.2 8.7 ± 0.8 Facial width change 8.7 ± 0.5 8.6 ± 0.6 8.8 ± 1.3 Vertical height change 8.8 ± 0.9 8.7 ± 0.6 8.9 ± 1.2 To assess the improvement in vertical facial proportions, we compared the preoperative and postoperative vertical distances of points A, Me, and B. This analysis aimed to determine whether the vertical proportion adjustments were due to changes in the maxilla, the mandible, or a combination of both. The comparison was made with reference to the average skull template and clinical observations, guiding the decision on whether to modify the maxilla, mandible, or both for each patient. The results, shown in Fig. 1 , indicated that for the majority of patients (63%), the improvement in facial proportions was achieved primarily by reducing the mandibular height. Nine patients underwent maxillary shortening (impaction), while three patients had both the maxilla and mandible shortened.. Discussion Maintaining facial harmony and proportions is crucial in orthognathic surgery (OGS), especially when treating patients with long faces or leptoprosopic (long) facial types. The vertical proportion of the face plays a key role in overall facial aesthetics. Franco et al. [ 15 ] highlighted the positive correlation between facial morphology and skull base structure. Dolichocephalic individuals, characterized by a longer, flatter skull base, often exhibit a more elongated anteroposterior dimension and a narrower transverse direction. This cranial morphology leads to a wider angle at the base of the skull, positioning the nasomaxillary complex lower and more protrusively, which, in turn, results in an inferior and posterior rotation of the mandible. Consequently, dolichocephalic individuals tend to develop longer faces with leptoprosopic features. As such, the vertical pattern of the face cannot be arbitrarily altered with OGS, as modifications to cranial shape are not feasible. This study validates the application of the Average Skull Template (AST) for both surgical planning and adjunctive diagnosis in patients with skeletal Class III and leptoprosopic facial characteristics. The treatment outcomes were highly satisfactory, achieving both functional and aesthetic improvements. As shown in Table 2 , significant improvements were noted in the anteroposterior direction, aligning the patients' skeletal relationships with a Class I profile. The discrepancies between the postoperative results and the average skull template were consistently less than 2 mm, indicating a high level of precision. The maxilla (point A) was notably closer to the average template than the mandible (points B, Pog, Me), likely due to the use of cutting and positional guides that minimized error during maxillary adjustments. While vertical deviations were greater than those observed in the anteroposterior and transverse planes, the overall vertical height was improved, moving closer to the ideal proportions. This variation may be attributed to the presence of hyperleptoprosopic facial types in some patients, which tend to retain a relatively long facial appearance even after surgical intervention. Patient-reported outcomes, as detailed in Table 3 , showed high satisfaction with the results of the surgical planning using the new method. The overall appearance rating (OAR) was 91.6, and satisfaction with facial appearance ranged from 8.5 to 9.3 out of 10. The highest satisfaction was reported with the chin's appearance, which likely reflects the positive outcomes of mandibular setback procedures, addressing concerns of a concave profile. Interestingly, the vertical height change received a slightly lower satisfaction score (8.8), despite a deviation of up to 3 mm from the template. This suggests that, for most patients, profile changes are of greater concern than vertical adjustments. In terms of vertical facial proportions, we used the leptoprosopic skull template to aid in diagnosing imbalanced maxillomandibular proportions and identifying the root causes of disproportionate vertical profiles, such as excessive maxillary height or chin projection. Our findings (Fig. 1 ) revealed that the primary cause of vertical imbalance was excessive chin growth, which diverges from previous studies suggesting maxillary impaction as the main solution for long-face patterns [ 17 , 18 ]. These discrepancies could be attributed to ethnic differences in facial morphology. In our institution, mesoprosopic facial types are the most common (47–55%), with leptoprosopic types comprising 25–30% of cases. A slightly higher proportion of leptoprosopic individuals were observed in our skeletal Class III patients, possibly due to increased mandibular growth. In line with this, 63% of our patients achieved vertical correction primarily through mandibular height reduction, whether by mandibular setback, clockwise rotation of the maxillomandibular complex (MMC), or genioplasty. Our study focuses on skeletal Class III patients requiring surgical correction, while long-face syndrome is typically more common in Class II patterns [ 19 ]. However, studies by Kuo et al. [ 20 ] suggest that for Class III patients with high-angle facial types, chin reduction plays a larger role than maxillary impaction, which mirrors the findings of our study. This suggests that the leptoprosopic average 3D template may provide valuable assistance in surgical planning for these patients. The leptoprosopic template offers a particularly effective tool for diagnosing and adjusting maxillary and mandibular positions in surgical planning for long-face patients. Compared to using a mesoprosopic (average) facial template, the new leptoprosopic template reduces adjustment time and increases accuracy, providing a tailored approach for long-face individuals. Our comparison of positional discrepancies between postoperative skulls and the average template (using paired landmarks) showed that the leptoprosopic template provides an ideal reference standard for surgeons. Additionally, patient satisfaction questionnaires assessing overall appearance and specific facial regions further validated the effectiveness of this approach. While the average skull template offers a straightforward and practical diagnostic tool, clinical examination remains essential to assess soft tissue characteristics, such as incisal show, gummy smile, and soft tissue facial proportions. Farkas' ideal vertical ratios, including a 1:1 upper-to-lower facial height ratio and a 1:2 upper-to-lower lip height ratio, are commonly used as guidelines [ 21 ]. In our clinical experience, the surgical movements simulated with the AST generally align well with clinical findings, though individual variances occasionally require additional consideration. It is essential to involve patients in discussions regarding their preferences and expected outcomes. The limitations of this study include a relatively small sample size and the inherent variability in facial proportions across different populations. Additionally, for patients with extremely long facial types, achieving results that perfectly match the template may be challenging due to surgical constraints. As such, clinical and practical considerations must always be incorporated into treatment planning. In conclusion, the development of the leptoprosopic average skull template has proven to be an effective tool for aiding diagnosis and treatment planning in long-face patients. This template enhances the efficiency and accuracy of surgical simulations, leading to more optimal facial proportions and improved patient outcomes. Methods Our study is structured into two key components: the development of the long facial type Average Skull Template (AST) and its application to prospective patient cases. The process of constructing the 3D craniofacial model for the long facial type and the workflow for 3D surgical planning and simulation follows the methodology outlined in our previous publication. For the prospective study, the design was adapted from our prior research and includes four distinct stages: (1) acquisition of 3D images, (2) surgical simulation using the 3D average skull template, (3) the execution of the actual surgery, and (4) post-surgical outcome validation. Ethics This study was conducted in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki and its subsequent amendments. Approval was obtained from the Institutional Review Board of the Chang Gung Medical Foundation (IRB approval number 202300094B0A3). All participants provided written informed consent before participating in the study. Study population This study aims to build upon our previous research on the 3D Average Skull Template (AST) for surgical simulation and planning by extending its application to patients with long facial types, which are commonly encountered in clinical practice. In the first phase, a 3D average template representing the long facial type will be developed using a cohort of Taiwanese individuals with long faces, including both male and female subjects. In the second phase, the newly established template will be applied in the treatment of patients presenting with long facial proportions. The facial type of each subject was determined using the facial index, a straightforward and effective method for assessing facial proportions. The facial index is calculated based on the ratio of bizygomatic width to anterior face height. Bizygomatic width is measured as the distance between the most laterally positioned points on the zygomatic arches, nasion is defined as the soft tissue point where the frontonasal suture intersects the midsagittal plane, and gnathion is the most inferior point on the lower border of the mandible. The facial index (FI) is calculated using the following formula [ 22 ]. Two distinct cohorts were included in this study: Group A: Normal Cohort with leptoprosopic facial type (long facial type): Participants in this group were selected based on their classification as having a leptoprosopic (long) facial type, as determined by the facial index, and none had previously undergone orthognathic surgery. The sample size was calculated using established methodologies from previous studies [ 13 , 23 , 24 ], with a required cohort size of 60 individuals (30 women and 30 men), with a mean age of 24.5 years. The sample size calculation for assessing the normative values was based on a two-tailed hypothesis test. An effect size of 0.5 was chosen to represent the smallest clinically detectable difference in millimeters, with an alpha error of 0.05 and a power of 0.7, yielding a total of 60 subjects. The inclusion criteria for the normal cohort were as follows: (1) Taiwanese Chinese ethnicity, (2) aged between 20 and 40 years, (3) a balanced facial profile with a leptoprosopic facial type (facial index > 0.9), (4) a normal interincisal relationship (with overbite and overjet ranging from 1 to 3 mm), and (5) a Class I skeletal relationship (indicated by a sell-nasion–A point angle between 2 and 4 degrees). Exclusion criteria included: (1) inability to undergo cone-beam computed tomography (CBCT) examination, (2) presence of acquired or inherited dentofacial deformities (such as cleft lip and palate, craniofacial syndromes, or post-traumatic deformities), or (3) prior history of plastic, maxillofacial, orthognathic, or reconstructive surgery. Following data collection on the skeletofacial characteristics of the participants, we created separate 3D skeletofacial models for male and female participants with long facial types. These models served as reference templates for surgical planning aimed at repositioning the maxillomandibular complex (MMC). A flowchart illustrating the development process of the 3D average template for normal long-face individuals, based on our previous publication [ 13 ], is shown in Fig. 2 . Group B: Surgery Cohort The surgical cohort consisted of 30 consecutive Taiwanese patients (14 females and 16 males) diagnosed with skeletal Class III malocclusion and leptoprosopic facial type, all of whom required two-jaw orthognathic surgery (OGS). The patients were enrolled between April 2023 and April 2024 and underwent pre-surgical simulation using the leptoprosopic average skull template. The average age of the cohort was 23.5 years, with participants ranging from 20 to 40 years old. Each patient presented with a Class III malocclusion, characterized by a long facial type, facial asymmetry, concave profile, negative ANB angle, and negative incisal overjet. All participants provided consent to undergo cone beam computed tomography (CBCT) scans for surgical simulation and planning. The orthodontic and surgical procedures were performed by the same specialists: Dr. CT Ho, the orthodontist, and Dr. LJ Lo, the surgeon. Exclusion criteria for this cohort included: (1) acquired or inherited dentofacial deformities (such as cleft lip and palate, craniofacial syndromes, or post-traumatic deformities), and (2) a history of previous plastic, maxillofacial, orthognathic, or reconstructive surgery. The study was approved by the Institutional Review Board of Chang Gung Medical Foundation (IRB approval number: 202300094B0A3), and all participants provided informed consent before inclusion in the study. Image acquisitions Each participant underwent a standard craniofacial CBCT scan using the KaVo ORTHOPANTOMOGRAPH™ OP 3D Vision X-ray system (DEXIS™, USA) with a low-dose protocol. The scan parameters included a 120 kVp setting, a voxel size of 0.4 mm × 0.4 mm × 0.4 mm, a scan duration of 26 seconds, and a field of view (FOV) of 11 cm × 23 cm × 17.3 cm. To ensure consistency in positioning, participants' head orientations were adjusted so that the Frankfort horizontal plane was parallel to the ground throughout the procedure. During the scan, participants were instructed to keep their head still, refrain from swallowing, maintain a closed mouth, and hold a centric occlusion bite. The acquired image data were saved in Digital Imaging and Communications in Medicine (DICOM) format and processed with a slice thickness of 0.4 mm [ 12 ]. Surgical Simulation Using 3D Average leptoprosopic (long) Skull as Template The average leptoprosopic skull template was used as a reference for surgical simulation. Two skull images were superimposed on the frontal-orbitale area, achieving the best match after resizing the average template. Deviations between the two skull images were then assessed in millimeters across the sagittal, frontal, and vertical planes to guide the simulation and planning process. Using Dolphin Imaging® 11.95 software (Chatsworth, CA, USA) [Ref PRS paper], virtual surgical occlusion was established. The maxilla and mandible were treated as a single unit (maxillomandibular complex, MMC) for movement simulation. The surgical plan was refined by aligning the MMC with the maxillary and mandibular positions of the average skull template (Fig. 3 ) [ 13 ]. Finally, the software calculated the 3-axis movement of key landmarks (A, B, Pog, Me, U1, U6), which formed the basis for the surgical plan. Surgical procedure Two jaw surgery were applied for all patients including a modified Hunsuck bilateral sagittal split All patients underwent two-jaw surgery, which included a modified Hunsuck bilateral sagittal split osteotomy, LeFort I osteotomy, and, if necessary, genioplasty. The single-splint method for surgical occlusion [ 25 ] was employed. Following mobilization of the maxilla and mandible, the distal mandibular segment was adjusted using the final occlusal splint to establish the occlusion with the maxilla, thereby creating the maxillomandibular complex (MMC). The MMC was then repositioned according to the planned position, guided by the 3D average skull template using a customized maxillary positioning guide. Validation of Post-Operative Outcome 1. Objective evaluation- Quantitative evaluation of postoperative outcome To assess the differences between postoperative results and the average skull, 3D models of the patients' skulls were converted into stereolithography (STL) files for alignment. The average skull models were then superimposed onto the patients' models in specific anatomical regions—such as the orbits, frontal area, upper third or half of the nose, and external zygoma—using seven pairs of anatomical landmarks (Nasion, Orbitale (L, R), Lateral Orbitale (L, R), Zygion (L, R)). The models were resized and aligned to achieve the best fit in both the anterior and lateral views, using the best-fit method [ 26 ]. Positional discrepancies, measured in millimeters, were evaluated at key anatomical landmarks, including the maxilla (point A), the midcontact point of the upper incisors (U1C), the mandible (point B), and the chin (points Pog and Me). These discrepancies were visualized and quantified using 3D software, with a focus on five pairs of anatomical landmarks (A, B, Pog, Me, U1). 2. Subjective evaluation - Patient reported outcome Six months post-surgery, patients completed self-administered questionnaires to assess their satisfaction with their facial appearance. Two key metrics were used to measure perceptions of facial aesthetics: the Overall Appearance Rating (OAR) and Satisfaction with Facial Appearance (SFA) [ 20 ]. The OAR evaluates the patient's perception of their ideal facial appearance on a scale from 0 to 100, with 1 representing extremely unattractive and 100 representing extremely attractive. The SFA measures satisfaction with specific facial features—including the nose, cheeks, lips, gum display, teeth, chin, and facial width—on a 1 to 10 scale, where 1 denotes very dissatisfied and 10 denotes very satisfied. Higher scores on both metrics indicate greater patient satisfaction and perceived facial attractiveness. Statistical methods Statistical analysis was conducted using SPSS Statistics 25 (SPSS Inc, Chicago, IL). Descriptive statistics, including means and standard deviations, were calculated for all measurements. Paired t-tests were performed to compare the T1 and T2 cephalometric values for each patient. A significance level of P < 0.05 was established for all statistical tests. Declarations Funding : No Funding Acknowledgement The authors would like to thank Uon Gin-Hang for his assistance during the imaging process, and the Center for Big Data Analytics and Statistics (Chang Gung Memorial Hospital) for their assistance in statistical analysis. This work was supported by grants from Chang Gung Memorial Hospital Grant (CMRPG3N1041). Author Contributions C-T. Ho conceived, designed, performed the experiments, and wrote the initial manuscript. Erica R-C. Lai and L-J. Lo helped with the designing and interpreting of the results. Erica R-C. Lai and W-C. Chiang analyzed the data. C-T. Ho and H-H. Lin conceived and designed the experiments, and completed the paper. Additional Information Competing financial interests: The authors declare no competing financial interests. References Sabri, R. Orthodontic objectives in orthognathic surgery: state of the art today. World J. Orthod. 7 (2), 177–191 (2006). Jeremić, D. et al. 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C., Bergeron, L., Lin, C. H., Chu, Y. M. & Chen, Y. R. Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry. Plast. Reconstr. Surg. 124 (3), 879–886 (2009). Hsu, P. J., Denadai, R., Pai, B. C. J., Lin, H. H. & Lo, L. J. Outcome of facial contour asymmetry after conventional two-dimensional versus computer-assisted three-dimensional planning in cleft orthognathic surgery. Sci. Rep. 10 (1), 2346 (2020). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 15 Oct, 2025 Editor assigned by journal 08 Oct, 2025 Editor invited by journal 26 Jun, 2025 Submission checks completed at journal 21 Jun, 2025 First submitted to journal 21 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6910341","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":534883097,"identity":"aaa2daae-8118-4175-ab9b-27351503600a","order_by":0,"name":"Rae-Chia (Erica) Lai","email":"","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Rae-Chia","middleName":"(Erica)","lastName":"Lai","suffix":""},{"id":534883098,"identity":"678887e8-57b9-4314-a123-69e158cd32a7","order_by":1,"name":"Hsiu-Hsia Lin","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hsiu-Hsia","middleName":"","lastName":"Lin","suffix":""},{"id":534883099,"identity":"41a1190f-9394-48de-8da1-638ff2bae131","order_by":2,"name":"Wen-Chung Chiang","email":"","orcid":"","institution":"Hungkuang University","correspondingAuthor":false,"prefix":"","firstName":"Wen-Chung","middleName":"","lastName":"Chiang","suffix":""},{"id":534883100,"identity":"7016ad3b-e3e3-417a-8566-487662f21398","order_by":3,"name":"Lun-Jou Lo","email":"","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":false,"prefix":"","firstName":"Lun-Jou","middleName":"","lastName":"Lo","suffix":""},{"id":534883101,"identity":"779f9e6b-8210-4eb9-b34f-59748a494509","order_by":4,"name":"Cheng-Ting Ho","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYFAC5uMfPlTYABmMjQeI1MKWxjjjTBpISwOxWnjMmHnbDoOZxGnRbT9g9nBm23m7te2HgbbU2EQT1GJ2JiHd4MO528nbziQCtRxLy20gqOVAwgHJGWW3k80OALUwNhwmQsv5hw3SPGznkkEMIrXcSGaT5mk7YGd2g2hbbjxjNpxxJjnB7AbQlgSi/HI+/+ODDxV29mbn0x8++FBjQ1gLDCSCVSYQqxwE7ElRPApGwSgYBSMMAADdl05pgm3ZJgAAAABJRU5ErkJggg==","orcid":"","institution":"Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":true,"prefix":"","firstName":"Cheng-Ting","middleName":"","lastName":"Ho","suffix":""}],"badges":[],"createdAt":"2025-06-17 05:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6910341/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6910341/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94672941,"identity":"020dd9e7-c783-4a59-830a-b099e985cbcb","added_by":"auto","created_at":"2025-10-29 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12:28:56","extension":"tif","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2258762,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/2b8b57494eebd330855cd091.tif"},{"id":94665572,"identity":"9461cabf-0b3f-4f49-acf1-f58f0dbf0d92","added_by":"auto","created_at":"2025-10-29 12:28:56","extension":"tif","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10170326,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2.tif","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/e045ab7d4be87eaa43ca95da.tif"},{"id":94672641,"identity":"6ffa49fe-33d4-413e-8005-6b698f74ef49","added_by":"auto","created_at":"2025-10-29 13:40:47","extension":"tif","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":3469530,"visible":true,"origin":"","legend":"","description":"","filename":"Figure3.tif","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/0664b84644ca5ec56dd10925.tif"},{"id":94673322,"identity":"b102fe59-f753-4f16-8216-11f14dc11ed6","added_by":"auto","created_at":"2025-10-29 13:41:20","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94316,"visible":true,"origin":"","legend":"","description":"","filename":"5ba3a0d8c7364c00bbf504810531f1ec1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/5c50b24cb5f84b967752c667.xml"},{"id":94665569,"identity":"97a871e0-32df-446a-90d4-3c986b16330b","added_by":"auto","created_at":"2025-10-29 12:28:56","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105797,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/132e5af9baaaac41a874c203.html"},{"id":94665570,"identity":"abff3849-e1a3-44db-a3d8-83fa79d89e56","added_by":"auto","created_at":"2025-10-29 12:28:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":186299,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Long Face Components: A pie chart illustrating the proportion of different components contributing to the long face phenotype.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/3e20fd8bc837d91a5d2c2c8c.png"},{"id":94672709,"identity":"2868383e-6c71-486f-8138-e8f001012f77","added_by":"auto","created_at":"2025-10-29 13:40:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2563479,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart for Constructing the 3D Average Template for Long Face: A step-by-step diagram depicting the process used to create the long face 3D average template.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/f273065d1dff7f23a3a3aa99.png"},{"id":94665566,"identity":"b06ef725-9981-46a7-afb2-3402155c5a69","added_by":"auto","created_at":"2025-10-29 12:28:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2413053,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical Simulation Workflow Using the Long Face 3D Average Skeletofacial Model: A flowchart detailing the use of our newly developed long face average 3D skeletofacial model as a template for surgical simulation, based on the methodology outlined in our previous work.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/54847615a1122545b74fb6d0.png"},{"id":94727950,"identity":"cd89a81b-f2f4-4b70-8f01-d8126dff4665","added_by":"auto","created_at":"2025-10-30 07:02:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5569341,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6910341/v1/0da0f870-568f-4062-af92-0dad2f5317ef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Leveraging a 3D Average Skeletofacial Model of Leptoprosopic Facial Type as a Template for Computer-Assisted Orthognathic Surgery Planning","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTreating patients with skeletal Class III malocclusion and leptoprosopic (long) facial types presents a longstanding challenge for both surgeons and orthodontists. Orthognathic surgery (OGS) aims not only to achieve an aesthetic facial profile and optimal dental occlusion but also to restore the proper facial vertical ratio and maintain natural facial proportions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. During surgery, it is critical to adjust skeletal positions while preserving individualized features, ensuring that these changes align with the underlying skull base morphology.\u003c/p\u003e\u003cp\u003eFacial parameters, including those related to facial morphology, have been described using the prosopic index, which is defined as the ratio of morphological facial height to bizygomatic width (facial breadth) multiplied by 100 (N-Me/ZY-ZY %) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Martin-Saller's scale classifies facial phenotypes into five categories: hyperleptoprosopic, leptoprosopic (long), mesoprosopic (medium), euryprosopic (short), and hypereuryprosopic [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These facial types are influenced by various factors such as sex, ethnicity, genetics, socio-economic status, and nutrition [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], with the distribution of these types varying across different populations and genders [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For instance, studies have found that the dominant facial type in Northern Iran is mesoprosopic, while the leptoprosopic face is most common among the Chinese population [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, research indicates a significant correlation between facial type and skull base morphology. Specifically, dolichocephalic skulls tend to be associated with leptoprosopic (long) faces, characterized by narrow arches and long facial indices. This relationship suggests that vertical facial patterns cannot be arbitrarily altered with OGS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, the surgical approach for long-faced patients must consider their cephalic index, facial index, and vertical ratios, rather than simply attempting to shorten the face.\u003c/p\u003e\u003cp\u003eIn an effort to improve the efficiency and objectivity of surgical planning, our research team previously developed a three-dimensional (3D) average model based on individuals with medium facial types to serve as a template for surgical simulations and planning [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This model has been shown to offer comparable accuracy to traditional 3D cephalometric standards and has demonstrated clinical success, leading to high patient satisfaction and reduced preoperative planning time [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, applying this medium facial template to long-face patients would compromise the natural vertical proportions and fail to align with the patient\u0026rsquo;s cranial base morphology. Studies have demonstrated a strong relationship between facial and skull morphology, highlighting the limitations of arbitrarily altering facial vertical patterns with OGS [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo our knowledge, no prior studies have utilized an average 3D template specifically tailored for diagnosing and planning surgery for long-face patients. The aim of this study is to extend our previous work by developing a 3D craniofacial template for individuals with leptoprosopic facial types, providing a more accurate reference for surgical planning. This template will not only optimize aesthetic and functional outcomes but also serve as a diagnostic tool to assist clinicians in adjusting vertical proportions of the upper and lower jaws. Additionally, this method can be used for teaching purposes, helping junior surgeons and orthodontists refine their diagnostic and treatment planning skills, ultimately enhancing the efficiency and effectiveness of their practice.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe intraobserver variability in landmark identification was minimal, with an average difference of 0.36 mm, ranging from 0.32 mm to 0.43 mm. Pearson correlation coefficients between the investigators' measurements (r\u0026thinsp;=\u0026thinsp;0.88 to 0.92; all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) indicated a strong and statistically significant correlation, confirming that the virtual-guided data collection process was both accurate and consistent (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\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\u003eIntraobserver Reproducibility of Landmark Identification in 3D Coordinate System: Assessment of consistency in landmark identification across repeated measurements.\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=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLandmark definition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean difference\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA point (A)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eU1 incisal tip\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB point (B)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePogonion (Pog)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMenton (Me)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eR, Pearson correlation coefficient, a p-value less than 0.05 is typically considered to be statistically significant.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the discrepancies between the postoperative results and the average skull template. The mean differences were analyzed across three anatomical planes: transverse (mediolateral, x-axis), sagittal (anteroposterior, y-axis), and vertical (superoinferior, z-axis). The results showed that the deviations in both the mediolateral and anteroposterior directions were consistently under 2 mm, which is well within the acceptable threshold [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, the superoinferior direction exhibited slightly larger discrepancies. Specifically, point A showed a discrepancy of 1.89 mm, while other landmarks displayed deviations ranging from 2 mm to 4 mm. This suggests that alignment was generally more accurate along the x-axis and y-axis, with a greater variability observed in the z-axis. Notably, the maxilla (point A: x\u0026thinsp;=\u0026thinsp;0.9 mm, y\u0026thinsp;=\u0026thinsp;1.1 mm, z\u0026thinsp;=\u0026thinsp;1.0 mm) showed the highest degree of alignment among all landmarks.\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\u003eDiscrepancy Between Postoperative Results and the Average Skull Template: Comparison of positional deviations across key anatomical landmarks.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMediolateral\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnteroposterior\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSuperoinferior\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eU1 mid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB point\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePog\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.47\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are in millimeters and are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the overall appearance rating (OAR) and satisfaction with facial aesthetics (SFA). Among the various facial features, the chin received the highest satisfaction scores, while the nose garnered lower ratings. All ratings were above 8 out of 10, indicating a high level of overall satisfaction. The substantial repositioning of the lower jaw following mandibular setback likely contributed to the increased satisfaction with chin positioning.\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\u003eOverall Appearance Rating (OAR) and Patient Satisfaction with Facial Aesthetics: Patient-reported outcomes on post-surgical facial appearance.\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\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eScale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eOrthognathic surgery-treated patients\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;16)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall appearance rating (0-100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eFacial area satisfaction (0\u0026ndash;10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCheek fullness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLip\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGum show\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDental alignment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacial width change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVertical height change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\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\u003eTo assess the improvement in vertical facial proportions, we compared the preoperative and postoperative vertical distances of points A, Me, and B. This analysis aimed to determine whether the vertical proportion adjustments were due to changes in the maxilla, the mandible, or a combination of both. The comparison was made with reference to the average skull template and clinical observations, guiding the decision on whether to modify the maxilla, mandible, or both for each patient. The results, shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, indicated that for the majority of patients (63%), the improvement in facial proportions was achieved primarily by reducing the mandibular height. Nine patients underwent maxillary shortening (impaction), while three patients had both the maxilla and mandible shortened..\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMaintaining facial harmony and proportions is crucial in orthognathic surgery (OGS), especially when treating patients with long faces or leptoprosopic (long) facial types. The vertical proportion of the face plays a key role in overall facial aesthetics. Franco et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] highlighted the positive correlation between facial morphology and skull base structure. Dolichocephalic individuals, characterized by a longer, flatter skull base, often exhibit a more elongated anteroposterior dimension and a narrower transverse direction. This cranial morphology leads to a wider angle at the base of the skull, positioning the nasomaxillary complex lower and more protrusively, which, in turn, results in an inferior and posterior rotation of the mandible. Consequently, dolichocephalic individuals tend to develop longer faces with leptoprosopic features. As such, the vertical pattern of the face cannot be arbitrarily altered with OGS, as modifications to cranial shape are not feasible.\u003c/p\u003e\u003cp\u003eThis study validates the application of the Average Skull Template (AST) for both surgical planning and adjunctive diagnosis in patients with skeletal Class III and leptoprosopic facial characteristics. The treatment outcomes were highly satisfactory, achieving both functional and aesthetic improvements. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, significant improvements were noted in the anteroposterior direction, aligning the patients' skeletal relationships with a Class I profile. The discrepancies between the postoperative results and the average skull template were consistently less than 2 mm, indicating a high level of precision. The maxilla (point A) was notably closer to the average template than the mandible (points B, Pog, Me), likely due to the use of cutting and positional guides that minimized error during maxillary adjustments.\u003c/p\u003e\u003cp\u003eWhile vertical deviations were greater than those observed in the anteroposterior and transverse planes, the overall vertical height was improved, moving closer to the ideal proportions. This variation may be attributed to the presence of hyperleptoprosopic facial types in some patients, which tend to retain a relatively long facial appearance even after surgical intervention.\u003c/p\u003e\u003cp\u003ePatient-reported outcomes, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, showed high satisfaction with the results of the surgical planning using the new method. The overall appearance rating (OAR) was 91.6, and satisfaction with facial appearance ranged from 8.5 to 9.3 out of 10. The highest satisfaction was reported with the chin's appearance, which likely reflects the positive outcomes of mandibular setback procedures, addressing concerns of a concave profile. Interestingly, the vertical height change received a slightly lower satisfaction score (8.8), despite a deviation of up to 3 mm from the template. This suggests that, for most patients, profile changes are of greater concern than vertical adjustments.\u003c/p\u003e\u003cp\u003eIn terms of vertical facial proportions, we used the leptoprosopic skull template to aid in diagnosing imbalanced maxillomandibular proportions and identifying the root causes of disproportionate vertical profiles, such as excessive maxillary height or chin projection. Our findings (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) revealed that the primary cause of vertical imbalance was excessive chin growth, which diverges from previous studies suggesting maxillary impaction as the main solution for long-face patterns [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These discrepancies could be attributed to ethnic differences in facial morphology. In our institution, mesoprosopic facial types are the most common (47\u0026ndash;55%), with leptoprosopic types comprising 25\u0026ndash;30% of cases. A slightly higher proportion of leptoprosopic individuals were observed in our skeletal Class III patients, possibly due to increased mandibular growth. In line with this, 63% of our patients achieved vertical correction primarily through mandibular height reduction, whether by mandibular setback, clockwise rotation of the maxillomandibular complex (MMC), or genioplasty.\u003c/p\u003e\u003cp\u003eOur study focuses on skeletal Class III patients requiring surgical correction, while long-face syndrome is typically more common in Class II patterns [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, studies by Kuo et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] suggest that for Class III patients with high-angle facial types, chin reduction plays a larger role than maxillary impaction, which mirrors the findings of our study. This suggests that the leptoprosopic average 3D template may provide valuable assistance in surgical planning for these patients.\u003c/p\u003e\u003cp\u003eThe leptoprosopic template offers a particularly effective tool for diagnosing and adjusting maxillary and mandibular positions in surgical planning for long-face patients. Compared to using a mesoprosopic (average) facial template, the new leptoprosopic template reduces adjustment time and increases accuracy, providing a tailored approach for long-face individuals. Our comparison of positional discrepancies between postoperative skulls and the average template (using paired landmarks) showed that the leptoprosopic template provides an ideal reference standard for surgeons. Additionally, patient satisfaction questionnaires assessing overall appearance and specific facial regions further validated the effectiveness of this approach.\u003c/p\u003e\u003cp\u003eWhile the average skull template offers a straightforward and practical diagnostic tool, clinical examination remains essential to assess soft tissue characteristics, such as incisal show, gummy smile, and soft tissue facial proportions. Farkas' ideal vertical ratios, including a 1:1 upper-to-lower facial height ratio and a 1:2 upper-to-lower lip height ratio, are commonly used as guidelines [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our clinical experience, the surgical movements simulated with the AST generally align well with clinical findings, though individual variances occasionally require additional consideration. It is essential to involve patients in discussions regarding their preferences and expected outcomes.\u003c/p\u003e\u003cp\u003eThe limitations of this study include a relatively small sample size and the inherent variability in facial proportions across different populations. Additionally, for patients with extremely long facial types, achieving results that perfectly match the template may be challenging due to surgical constraints. As such, clinical and practical considerations must always be incorporated into treatment planning.\u003c/p\u003e\u003cp\u003eIn conclusion, the development of the leptoprosopic average skull template has proven to be an effective tool for aiding diagnosis and treatment planning in long-face patients. This template enhances the efficiency and accuracy of surgical simulations, leading to more optimal facial proportions and improved patient outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eOur study is structured into two key components: the development of the long facial type Average Skull Template (AST) and its application to prospective patient cases. The process of constructing the 3D craniofacial model for the long facial type and the workflow for 3D surgical planning and simulation follows the methodology outlined in our previous publication. For the prospective study, the design was adapted from our prior research and includes four distinct stages: (1) acquisition of 3D images, (2) surgical simulation using the 3D average skull template, (3) the execution of the actual surgery, and (4) post-surgical outcome validation.\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki and its subsequent amendments. Approval was obtained from the Institutional Review Board of the Chang Gung Medical Foundation (IRB approval number 202300094B0A3). All participants provided written informed consent before participating in the study.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThis study aims to build upon our previous research on the 3D Average Skull Template (AST) for surgical simulation and planning by extending its application to patients with long facial types, which are commonly encountered in clinical practice. In the first phase, a 3D average template representing the long facial type will be developed using a cohort of Taiwanese individuals with long faces, including both male and female subjects. In the second phase, the newly established template will be applied in the treatment of patients presenting with long facial proportions. The facial type of each subject was determined using the facial index, a straightforward and effective method for assessing facial proportions. The facial index is calculated based on the ratio of bizygomatic width to anterior face height. Bizygomatic width is measured as the distance between the most laterally positioned points on the zygomatic arches, nasion is defined as the soft tissue point where the frontonasal suture intersects the midsagittal plane, and gnathion is the most inferior point on the lower border of the mandible. The facial index (FI) is calculated using the following formula [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003eTwo distinct cohorts were included in this study:\u003c/p\u003e\n\u003ch3\u003eGroup A: Normal Cohort with leptoprosopic facial type (long facial type):\u003c/h3\u003e\n\u003cp\u003eParticipants in this group were selected based on their classification as having a leptoprosopic (long) facial type, as determined by the facial index, and none had previously undergone orthognathic surgery. The sample size was calculated using established methodologies from previous studies [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], with a required cohort size of 60 individuals (30 women and 30 men), with a mean age of 24.5 years. The sample size calculation for assessing the normative values was based on a two-tailed hypothesis test. An effect size of 0.5 was chosen to represent the smallest clinically detectable difference in millimeters, with an alpha error of 0.05 and a power of 0.7, yielding a total of 60 subjects.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria for the normal cohort were as follows: (1) Taiwanese Chinese ethnicity, (2) aged between 20 and 40 years, (3) a balanced facial profile with a leptoprosopic facial type (facial index\u0026thinsp;\u0026gt;\u0026thinsp;0.9), (4) a normal interincisal relationship (with overbite and overjet ranging from 1 to 3 mm), and (5) a Class I skeletal relationship (indicated by a sell-nasion\u0026ndash;A point angle between 2 and 4 degrees). Exclusion criteria included: (1) inability to undergo cone-beam computed tomography (CBCT) examination, (2) presence of acquired or inherited dentofacial deformities (such as cleft lip and palate, craniofacial syndromes, or post-traumatic deformities), or (3) prior history of plastic, maxillofacial, orthognathic, or reconstructive surgery.\u003c/p\u003e\n\u003cp\u003eFollowing data collection on the skeletofacial characteristics of the participants, we created separate 3D skeletofacial models for male and female participants with long facial types. These models served as reference templates for surgical planning aimed at repositioning the maxillomandibular complex (MMC).\u003c/p\u003e\n\u003cp\u003eA flowchart illustrating the development process of the 3D average template for normal long-face individuals, based on our previous publication [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e], is shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eGroup B: Surgery Cohort\u003c/h2\u003e\n \u003cp\u003eThe surgical cohort consisted of 30 consecutive Taiwanese patients (14 females and 16 males) diagnosed with skeletal Class III malocclusion and leptoprosopic facial type, all of whom required two-jaw orthognathic surgery (OGS). The patients were enrolled between April 2023 and April 2024 and underwent pre-surgical simulation using the leptoprosopic average skull template. The average age of the cohort was 23.5 years, with participants ranging from 20 to 40 years old. Each patient presented with a Class III malocclusion, characterized by a long facial type, facial asymmetry, concave profile, negative ANB angle, and negative incisal overjet. All participants provided consent to undergo cone beam computed tomography (CBCT) scans for surgical simulation and planning.\u003c/p\u003e\n \u003cp\u003eThe orthodontic and surgical procedures were performed by the same specialists: Dr. CT Ho, the orthodontist, and Dr. LJ Lo, the surgeon. Exclusion criteria for this cohort included: (1) acquired or inherited dentofacial deformities (such as cleft lip and palate, craniofacial syndromes, or post-traumatic deformities), and (2) a history of previous plastic, maxillofacial, orthognathic, or reconstructive surgery.\u003c/p\u003e\n \u003cp\u003eThe study was approved by the Institutional Review Board of Chang Gung Medical Foundation (IRB approval number: 202300094B0A3), and all participants provided informed consent before inclusion in the study.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eImage acquisitions\u003c/h3\u003e\n\u003cp\u003eEach participant underwent a standard craniofacial CBCT scan using the KaVo ORTHOPANTOMOGRAPH\u0026trade; OP 3D Vision X-ray system (DEXIS\u0026trade;, USA) with a low-dose protocol. The scan parameters included a 120 kVp setting, a voxel size of 0.4 mm \u0026times; 0.4 mm \u0026times; 0.4 mm, a scan duration of 26 seconds, and a field of view (FOV) of 11 cm \u0026times; 23 cm \u0026times; 17.3 cm. To ensure consistency in positioning, participants\u0026apos; head orientations were adjusted so that the Frankfort horizontal plane was parallel to the ground throughout the procedure. During the scan, participants were instructed to keep their head still, refrain from swallowing, maintain a closed mouth, and hold a centric occlusion bite. The acquired image data were saved in Digital Imaging and Communications in Medicine (DICOM) format and processed with a slice thickness of 0.4 mm [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSurgical Simulation Using 3D Average leptoprosopic (long) Skull as Template\u003c/h3\u003e\n\u003cp\u003eThe average leptoprosopic skull template was used as a reference for surgical simulation. Two skull images were superimposed on the frontal-orbitale area, achieving the best match after resizing the average template. Deviations between the two skull images were then assessed in millimeters across the sagittal, frontal, and vertical planes to guide the simulation and planning process. Using Dolphin Imaging\u0026reg; 11.95 software (Chatsworth, CA, USA) [Ref PRS paper], virtual surgical occlusion was established. The maxilla and mandible were treated as a single unit (maxillomandibular complex, MMC) for movement simulation. The surgical plan was refined by aligning the MMC with the maxillary and mandibular positions of the average skull template (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Finally, the software calculated the 3-axis movement of key landmarks (A, B, Pog, Me, U1, U6), which formed the basis for the surgical plan.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSurgical procedure\u003c/h2\u003e\n \u003cp\u003eTwo jaw surgery were applied for all patients including a modified Hunsuck bilateral sagittal split All patients underwent two-jaw surgery, which included a modified Hunsuck bilateral sagittal split osteotomy, LeFort I osteotomy, and, if necessary, genioplasty. The single-splint method for surgical occlusion [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e] was employed. Following mobilization of the maxilla and mandible, the distal mandibular segment was adjusted using the final occlusal splint to establish the occlusion with the maxilla, thereby creating the maxillomandibular complex (MMC). The MMC was then repositioned according to the planned position, guided by the 3D average skull template using a customized maxillary positioning guide.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eValidation of Post-Operative Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e1. Objective evaluation- Quantitative evaluation of postoperative outcome\u003c/h2\u003e\n \u003cp\u003eTo assess the differences between postoperative results and the average skull, 3D models of the patients\u0026apos; skulls were converted into stereolithography (STL) files for alignment. The average skull models were then superimposed onto the patients\u0026apos; models in specific anatomical regions\u0026mdash;such as the orbits, frontal area, upper third or half of the nose, and external zygoma\u0026mdash;using seven pairs of anatomical landmarks (Nasion, Orbitale (L, R), Lateral Orbitale (L, R), Zygion (L, R)). The models were resized and aligned to achieve the best fit in both the anterior and lateral views, using the best-fit method [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. Positional discrepancies, measured in millimeters, were evaluated at key anatomical landmarks, including the maxilla (point A), the midcontact point of the upper incisors (U1C), the mandible (point B), and the chin (points Pog and Me). These discrepancies were visualized and quantified using 3D software, with a focus on five pairs of anatomical landmarks (A, B, Pog, Me, U1).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e2. Subjective evaluation - Patient reported outcome\u003c/h2\u003e\n \u003cp\u003eSix months post-surgery, patients completed self-administered questionnaires to assess their satisfaction with their facial appearance. Two key metrics were used to measure perceptions of facial aesthetics: the Overall Appearance Rating (OAR) and Satisfaction with Facial Appearance (SFA) [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. The OAR evaluates the patient\u0026apos;s perception of their ideal facial appearance on a scale from 0 to 100, with 1 representing extremely unattractive and 100 representing extremely attractive. The SFA measures satisfaction with specific facial features\u0026mdash;including the nose, cheeks, lips, gum display, teeth, chin, and facial width\u0026mdash;on a 1 to 10 scale, where 1 denotes very dissatisfied and 10 denotes very satisfied. Higher scores on both metrics indicate greater patient satisfaction and perceived facial attractiveness.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical methods\u003c/h2\u003e\n \u003cp\u003eStatistical analysis was conducted using SPSS Statistics 25 (SPSS Inc, Chicago, IL). Descriptive statistics, including means and standard deviations, were calculated for all measurements. Paired t-tests were performed to compare the T1 and T2 cephalometric values for each patient. A significance level of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was established for all statistical tests.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding :\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo Funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Uon Gin-Hang for his assistance during the imaging process, and the Center for Big Data Analytics and Statistics (Chang Gung Memorial Hospital) for their assistance in statistical analysis. This work was supported by grants from Chang Gung Memorial Hospital Grant (CMRPG3N1041).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC-T. Ho conceived, designed, performed the experiments, and wrote the initial manuscript. Erica R-C. Lai and L-J. Lo helped with the designing and interpreting of the results. Erica R-C. Lai and W-C. Chiang analyzed the data. C-T. Ho and H-H. Lin conceived and designed the experiments, and completed the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompeting financial interests: The authors declare no competing financial interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSabri, R. Orthodontic objectives in orthognathic surgery: state of the art today. \u003cem\u003eWorld J. 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H., Chu, Y. M. \u0026amp; Chen, Y. R. Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry. \u003cem\u003ePlast. Reconstr. Surg.\u003c/em\u003e \u003cb\u003e124\u003c/b\u003e (3), 879\u0026ndash;886 (2009).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHsu, P. J., Denadai, R., Pai, B. C. J., Lin, H. H. \u0026amp; Lo, L. J. Outcome of facial contour asymmetry after conventional two-dimensional versus computer-assisted three-dimensional planning in cleft orthognathic surgery. \u003cem\u003eSci. Rep.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e (1), 2346 (2020).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Leptoprosopic facial type, Orthognathic surgery, Simulation, Facial proportion","lastPublishedDoi":"10.21203/rs.3.rs-6910341/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6910341/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSurgical planning for patients with skeletal Class III malocclusion and leptoprosopic (long) facial characteristics presents unique challenges, especially when striving for optimal facial aesthetics and proportional balance. This study sought to refine traditional surgical planning methods by developing a specialized 3D craniofacial template for individuals with leptoprosopic facial morphology. We constructed this template using 60 skeletal Class I patients with leptoprosopic features, all of whom had not undergone prior orthognathic surgery. The template was then applied in virtual surgical simulations for 30 skeletal Class III patients with similar facial types, guiding the adjustment of anteroposterior, transverse, and vertical skeletal dimensions. Postoperative CBCT scans were compared to the template to assess the alignment of the jaw positions, while patient satisfaction was measured through a structured questionnaire. The findings revealed minimal discrepancies between postoperative outcomes and the template, with jaw position deviations of less than 2 mm in the anteroposterior and transverse planes, and slight increases (1.8\u0026ndash;3.6 mm) in the vertical direction. Notably, the patients reported the highest satisfaction with improvements in chin projection, and most also appreciated changes in vertical facial height. Additionally, 63% of patients experienced a reduction in mandibular height following vertical adjustments. In conclusion, the creation of a tailored leptoprosopic skull template offers a valuable tool for improving the accuracy of surgical planning and enhancing aesthetic outcomes for long-face patients, contributing to more precise treatment and better overall results.\u003c/p\u003e","manuscriptTitle":"Leveraging a 3D Average Skeletofacial Model of Leptoprosopic Facial Type as a Template for Computer-Assisted Orthognathic Surgery Planning","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 12:28:51","doi":"10.21203/rs.3.rs-6910341/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-10-15T14:41:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-08T06:09:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-26T07:09:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-22T02:18:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-06-22T02:15:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7937c3f5-4089-427c-9ac3-1340b344498f","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":56869421,"name":"Health sciences/Diseases"},{"id":56869422,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-10-29T12:28:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 12:28:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6910341","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6910341","identity":"rs-6910341","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}