Fractal analysis of the mandibular ramus in class II and III patients undergoing orthognathic surgery: Retrospective study trough Cone-beam Computed Tomography

Fractal analysis of the mandibular ramus in class II and III patients undergoing orthognathic surgery: Retrospective study trough Cone-beam Computed Tomography | 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 Fractal analysis of the mandibular ramus in class II and III patients undergoing orthognathic surgery: Retrospective study trough Cone-beam Computed Tomography Isabela Inoue Kussaba, Beatriz Caio Felipe, Rodrigo Lorenzi Poluha, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4426661/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Jul, 2025 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract One of the challenges of orthognathic surgery (OS) is maintaining condylar position during osteosynthesis. It is believed that the post-surgical condylar position is related to postoperative morphological changes in the temporomandibular joint (TMJ), as well as surgical stability. Therefore, the aim of this study is to perform fractal analysis of the mandibular ramus in class II and class III patients undergoing OS, analyzing cone beam computed tomography (CBCT) images one month before surgery (T0), one month after surgery (T1), and six to eight months after surgery (T2). Fractal analysis was performed on coronal and sagittal reconstructions. Regions of interest (ROIs) were selected for each patient and evaluated region. The ROIs underwent a processing method described by White & Rudolph in 1999. After processing, fractal analysis calculation was performed using the box-counting method by the "Fractal Box Count" function of the ImageJ software. When examining the different periods (T0, T1, and T2) among class II and class III patients, no statistically significant differences were identified (p > 0.05). This finding suggests stability in the fractal characteristics of the analyzed region, regardless of skeletal class. Thus, OS for correction of Class II and Class III malocclusions did not demonstrate a significant impact on the microstructure of the mandibular ramus over time. Fractal analysis Orthognathic surgery Temporomandibular joint Cone beam computed tomography Three-dimensional analysis Figures Figure 1 Figure 2 Figure 3 1 Introduction Severe malocclusions accompanied by skeletal discrepancies can result in a variety of functional and aesthetic alterations. The approach to correcting these deformities involves careful integration of orthodontic treatment and orthognathic surgery (OS). Orthognathic surgical procedures are traditionally performed following preoperative orthodontic preparation aimed at leveling and decompensating the dental arches. Subsequently, surgery is followed by postoperative orthodontic therapy, aiming to stabilize surgical outcomes and improve occlusal relationship [ 1 ]. However, in OS, one of the central challenges is maintaining the proper position of the mandibular ramus during osteosynthesis. This is crucial because the postoperative condylar position is directly linked to morphological changes in the temporomandibular joint (TMJ), playing a critical role in surgical stability. Thus, preserving the physiological position of the mandibular ramus and reducing intraoperative condylar movement continue to be the gold standard for minimizing postoperative TMJ symptoms [ 2 ]. Bilateral sagittal osteotomy stands out as the most used surgical technique to correct skeletal class II and III discrepancies [ 3 ]. Three-dimensional (3D) changes in the position of the mandible, maxilla, or both, resulting from OS, impact not only the TMJ but also the masticatory musculature, surrounding soft tissues, and consequently, the signs and symptoms of temporomandibular disorders (TMDs) [ 4 ]. Mandibular advancement tends to result in an anterior position of the mandibular ramus in the mandibular fossa, inducing the entire mandibular ramus/temporomandibular disc complex to follow this movement for a period. Additionally, this new anterior mandibular posture often demands adaptation of the surrounding soft tissue, with significant implications for muscle fibers. It is evident that such therapeutic approach often triggers a series of changes in the stomatognathic system. The natural adaptive capacity of the TMJs, when exceeded, can result in condylar remodeling [ 5 ]. However, despite the diversity of observed alterations, little is known about the true impact of protrusion as a predisposing, initiating, or perpetuating factor of TMDs [ 6 ]. In the literature, no study to date has evaluated the effect of OS in Class II and Class III malocclusion patients on the microstructure of the mandibular ramus through computed tomography (CT) using fractal analysis. Three-dimensional diagnostic techniques offer enhanced precision in image acquisition. Cone beam computed tomography (CBCT) provides high-resolution images for the evaluation and quantification of facial bone tissues in real dimensions (1:1 ratio), eliminating magnification or distortion and thus offering greater anatomical precision. Additionally, it highlights cost reduction, lower radiation exposure, and shorter acquisition time compared to helical CT [ 7 ]. CBCT enables detailed evaluation of cortical bone, condylar position, mandibular fossa, articular eminence, and joint spaces. Its ability to provide high-quality images makes it suitable for detecting progressive bone changes such as osteophyte formation, erosion, condylar flattening, sclerosis, concavity, and subcortical cysts [ 8 ]. Furthermore, CBCT is widely used in clinical diagnosis, with volumetric analysis from this technique considered reliable and precise in evaluating changes in the mandibular ramus [ 9 ]. In Dentistry, fractal analysis was first used in 1999 to evaluate changes in the pattern of trabecular bone in the mandible and maxilla of patients with osteoporosis [ 10 ]. Since then, it has been a method used to assess changes in trabecular bone. Fractal dimension (FD), obtained from radiographs or tomographs [ 11 ], is a measure that allows interpretation of the microstructure of trabecular bone [ 12 ]. Higher FD values are associated with a complex bone structure, characterized by denser and less porous trabecular architecture [ 13 ]. Since direct visualization of degenerative changes in the bony components of the temporomandibular joint (TMJ) is not always practical, fractal analysis emerges as an effective approach to overcome this limitation. Assessing the bone remodeling of the mandibular ramus post-OS is essential for monitoring joint health evolution and developing effective treatment strategies. Understanding changes in condylar bone structure over time after OS is important for precise clinical monitoring and for anticipating and correcting potential complications, aiming to optimize clinical outcomes and patient quality of life. Thus, the aim of the present study is to perform fractal analysis of the mandibular ramus in Class II and Class III patients undergoing OS, analyzing CBCT scans one month before OS (T0), one month after OS (T1), and six to eight months after OS (T2). The null hypothesis of this study posits that OS does not interfere with the bone quality of the mandibular ramus and its capacity for adaptation over time. 2 Methodology The present retrospective cohort study was approved by the Permanent Committee of Ethics in Research Involving Human Subjects of the State University of Maringá (UEM) (opinion: CAAE: 65405022.2.0000.0104) and developed following the recommendations of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [14]. Due to the retrospective nature of this study, the Committee did not require the signing of informed consent forms. 2.1 Sample The sample was conveniently selected, comprising 30 CBCT scans of Class II patients (undergoing maxillomandibular advancement) and another 32 of Class III patients (undergoing maxillary advancement and mandibular setback surgery) [15]. All patients underwent OS and were operated on by the team from the Residency Program in Oral and Maxillofacial Surgery and Traumatology at UEM. 2.2 Inclusion and Exclusion Criteria For this study, we included CBCT scans of patients over 18 years of age, of both sexes, diagnosed with skeletal Class II and Class III malocclusions according to Angle classification, who underwent OS. Patients with craniofacial syndromes, previous alterations in the temporomandibular joint (TMJ), or incomplete documentation were excluded. From this selection, five patients were excluded: two due to a condition called retrusive mandibular ramus, two due to incomplete documentation, and one due to having a craniofacial syndrome, resulting in a final sample of 57 patients. 2.3 Surgical Technique Mandibular advancement and setback were performed using bilateral sagittal split ramus osteotomy; maxillary osteotomies were performed using the Le Fort I osteotomy technique [15,16]. The sagittal split ramus osteotomy is the most used procedure in orthognathic surgery. Its versatility is due to its design offering a wide area of contact between the bone segments, which provides better healing and greater stability. The fixation technique for the mandibular osteotomy was the hybrid technique, which reduces the risk of condylar torque and subsequent resorption. On the other hand, the Le Fort I osteotomy is indicated for moving the maxilla in three spatial planes, as well as leveling dental arches, modifying arch shapes, and coordinating transverse discrepancies between the maxillary and mandibular arches [17]. CBCT scans were collected from April 2014 to February 2022. Fractal analysis of the images was performed at three different time points: one month before OS (T0), one month after the intervention (T1), and between six and eight months after OS (T2). 2.4 Image Acquisition The CBCT scans were performed at the Laboratory of Images in Clinical Research (LIPC) of the Health Technology Center (CTS), part of the Complex of Support Centers for Research (COMCAP), located in the Department of Dentistry at the State University of Maringá (DOD-UEM). All images were captured by a specialist in Dental Radiology and Imaging, using the i-CAT Next Generation® equipment (Imaging Sciences International, Hatfield, PA, USA). During the procedure, patients were instructed to sit still, adopt a natural head position, breathe calmly, and keep their tongue and lips at rest [18]. Chin and head support were removed during image acquisition to prevent soft tissue alterations. 2.5 Evaluators and Image Region Selection All analyses were conducted by one evaluator using ImageJ software (version 2.0.0), a public domain tool provided by the National Institutes of Health, Bethesda, Md, USA (https://imagej.nih.gov/ij). According to the guidelines of the Examiner Calibration Manual published by the Brazilian Ministry of Health in 2001, the evaluator underwent a calibration and training process. The training included a detailed theoretical discussion of all criteria used in the evaluation. Then, a practical training session was conducted, during which the examiner analyzed the same exams at different times. Possible discrepancies in the results were discussed to reach a consensus on the rules and criteria for CBCT evaluation. Finally, effective calibration was performed by calculating intra-rater agreement using the Intraclass Correlation Coefficient (ICC) [19]. All CBCT scans were analyzed twice, with a 15-day interval, by the same examiner. The fractal analysis was performed on a computer equipped with the Microsoft Windows XP Professional SP-2 operating system (Microsoft Corp., Redmond, WA, USA), Intel® CoreTM 2 Duo 1.86 GHz-6300 processor (Intel Corporation, USA), NVIDIA GeForce 6200 Turbo Cache graphics card (NVIDIA Corporation, USA), and EIZO - S2000 FlexScan monitor, resolution of 1600 × 1200 pixels (EIZO Nanao Corporation, Hakusan, Japan). The analyses were conducted on coronal and sagittal reconstructions. For this purpose, Regions of Interest (ROIs) were selected for each patient and evaluated region. Axial sections with a slice thickness of 0.3 mm were examined, and a coronal image was selected at the widest part in the mediolateral dimension of the mandibular head. Similarly, coronal sections with the same slice thickness were examined, and the sagittal image passing through the middle of the mandibular head was chosen. Coronal and sagittal images of all mandibular heads underwent fractal analysis, as described by KOCAK et al., in 2021 [8,20]. This method was performed on each patient on both right and left mandibular heads. The CBCT scans were opened in ImageJ software. In each CBCT image in the coronal reconstruction, a round ROI of 25x25 pixels was selected in the region of the trabecular bone of the mandibular head (Figure 01). In sagittal reconstructions, a ROI of 20x20 pixels was chosen [21]. Figure 01. A: ROI selection in the coronal reconstruction. B: ROI selection in the sagittal reconstruction. 2.6 Fractal evaluation of condylar bone trabeculation in Class II and Class III patients undergoing orthognathic surgery. Fractal evaluation of condylar bone trabeculation in Class II and Class III patients undergoing orthognathic surgery followed the steps described by White & Rudolph, 1999 [10], using ImageJ software. The process comprised the following steps (Figure 02): Duplication of the original image: Creation of a copy of the original image. Application of Gaussian filter: Removal of low and medium-scale structures, retaining Only significant density variations, i.e. high contrast. Subtraction and Addition of gray value: Subtraction of the second image from the original. Addition of a gray value of 128 to each pixel, generating an image with an average gray value of 128, highlighting specific individual brightness variations, such as the bone trabeculae of the mandibular head. Binary Image Transformation: Image segmentation to visually highlight structures radiographically similar to bone trabeculae. Erozion and Dilation: Process for noise reduction. Skeletonization: Erosion of the image until only the central line of pixels remains. Figure 02. Fractal analysis according to the method of White and Rudolph, 1999. Protocol used: (A) original image; (B) application of Gaussian blur filter; (C) subtraction of the first image and addition of gray values at 128 pixels; (D) image binarization; (E) result after image skeletonization. After processing, fractal analysis was calculated using the box counting method by the "Fractal Box Count" function of the ImageJ software [19]. 2.7 Evaluation of condylar bone cortex in Class II and Class III patients undergoing orthognathic surgery. The evaluation of condylar bone cortex in Class II and Class III patients undergoing orthognathic surgery was measured in millimeters on two different tomographic reconstructions positioned in the center of the mandibular head: sagittal and axial reconstructions. In the sagittal reconstruction, the cortical thickness in millimeters was measured at the top region of the mandibular head, while in the axial reconstruction, the cortical thickness was measured at four different points: anterior, posterior, mediolateral, and distolateral. These measurements were performed using Imaging Studio software (Figure 03). Figure 03. A: Measurements performed in the axial reconstruction. B: Measurement performed in the sagittal reconstruction of the bone cortex. 2.8 Statistical Analysis In this study, we adopted a statistical design that includes the evaluation of intra-rater agreement, using the Intraclass Correlation Coefficient (ICC). For all statistical analyses, we used Jamovi software, an open-source statistical platform that offers a wide range of tools for data analysis (available at www.jamovi.org). Initially, the data were subjected to descriptive analysis. To check the normality of the data distribution, we employed the Shapiro-Wilk test, setting p<0.05 as the threshold for significance. We proceeded with the statistical comparison of the values obtained in fractal evaluations and cortical thickness measurements. For this purpose, we analyzed images of the same regions, both in preoperative and postoperative periods, using the Friedman test. This test was chosen for its suitability in analyzing differences within related groups when the data do not follow a normal distribution. We adopted p<0.05 as the criterion for determining the statistical significance of these comparisons. 3 Results 3.1 Participant Characteristics: Age and Gender The sample in this study comprised a total of 57 patients, with 27 classified as Class II and 30 as Class III. In Class II, there were 22 female and 5 male patients, with ages ranging from 19 to 49 years. However, in Class III, consisting of 30 patients, the distribution was 16 female and 14 male patients, with ages ranging from 18 to 44 years. 3.2 Fractal Analysis The fractal analysis (Table 01 ) provided a detailed approach to fractal values, presenting medians, standard deviations, minimum and maximum values at different time points (pre- and post-operative) of images from the same region. Upon examining the different periods (T0, T1, and T2) of patient groups from Classes II and III, no statistically significant differences were identified (p > 0.05). 3.3 Cortical Thickness The evaluation of cortical thickness (Table 02 ) was conducted, and no statistically significant differences were observed for both Class II and Class III patients when comparing different pre- and post-operative time points of images from the same region (p > 0.05). Table 01 Descriptive analysis of fractal value for Class II and Class III patients in preoperative and postoperative periods. Class II Class III T0 T1 T2 T0 T1 T2 N 27 27 27 30 30 30 RIGHT CORONAL RECONSTRUCTION Median 1.32 1.31 1.33 1.40 1.34 1.39 Standard deviation 0.0598 0.0712 0.0702 0.163 0.194 0.203 Minimum 1.19 1.17 1.16 1.04 0.710 0.593 Maximum 1.39 1.42 1.40 1.72 1.60 1.65 SAGITAL RECONSTRUCTION Median 1.11 1.15 1.13 0.826 0.826 0.826 Standard deviation 0.119 0.124 0.0700 0.263 0.198 0.189 Minimum 0.594 0.594 1.00 0.359 0.359 0.476 Maximum 1.25 1.25 1.25 1.67 1.14 1.14 Shapiro-wilk test p > 0,05 Friedman test p > 0,05 Shapiro-wilk test p > 0,05 Friedman test p > 0,05 LEFT CORONAL RECONSTRUCTION Median 1.35 1.34 1.31 1.41 1.41 1.43 Standard deviation 0.0618 0.0466 0.0447 0.204 0.200 0.173 Minimum 1.06 1.23 1.23 0.594 0.594 0.826 Maximum 1.38 1.38 1.39 1.67 1.65 1.67 SAGITAL RECONSTRUCTION Median 1.13 1.15 1.14 0.710 0.826 0.879 Standard deviation 0.0844 0.0841 0.108 0.181 0.196 0.198 Minimum 0.826 0.826 0.710 0.359 0.359 0.283 Maximum 1.24 1.27 1.25 1.09 1.16 1,09 Shapiro-wilk test p > 0,05 Friedman test p > 0,05 Shapiro-wilk test p > 0,05 Friedman test p > 0,05 Table 02 Descriptive analysis of cortical thickness (mm) for Class II and Class III patients in preoperative and postoperative periods. RIGHT LEFT Class II Class III Class II Class III T0 T1 T2 T0 T1 T2 T0 T1 T2 T0 T1 T2 N 27 27 27 30 30 30 27 27 27 30 30 30 SAGITAL RECONSTRUCTION Top Median 0.961 0.912 0.941 0.842 0.825 0.903 0.915 1.03 0.796 0.789 0.679 0.701 Standard Deviation 0.226 0.348 0.317 0.335 0.445 0.314 0.382 0.380 0.265 0.762 0.564 0.718 Minimum 0.453 0.00 0.00 0.423 0.00 0.288 0.418 0.468 0.00 0.00 0.00 0.00 Maximum 1.27 1.74 1.58 1.97 2.25 1.70 2.09 1.83 1.30 4.32 3.13 3.90 AXIAL RECONSTRUCION Anterior Median 0.950 1.04 1.15 0.853 0.871 0.847 1.00 1.06 1.17 0.840 0.679 0.784 Standard Deviation 0.393 0.641 0.468 0.308 0.319 0.278 0.563 0.602 0.626 0.293 0.386 0.307 Minimum 0.664 0.683 0.588 0.670 0.516 0.486 0.519 0.527 0.535 0.492 0.335 0.340 Maximum 2.24 3.45 2.45 2.08 1.90 1.77 2.71 2.99 3.12 1.74 1.95 1.88 Posterior Median 0.810 0.764 0.725 0.692 0.702 0.718 0.718 0.663 0.710 0.684 0.653 0.689 Standard Deviation 0.204 0.242 0.184 0.292 0.256 0.203 0.229 0.215 0.248 0.374 0.251 0.247 Minimum 0.371 0.00 0.519 0.00 0.00 0.00 0.515 0.424 0.00 0.00 0.00 0.00 Maximum 1.24 1.16 1.21 1.43 1.22 1.03 1.38 1.47 1.00 2.01 1.25 1.21 Mediolateral Median 0.850 0.830 0.928 0.695 0.780 0.704 0.846 0.813 0.817 0.714 0.690 0.788 Standard Deviation 0.247 0.238 0.388 0.400 0.617 0.451 0.311 0.356 0.382 0.295 0.363 0.314 Minimum 0.542 0.436 0.346 0.00 0.00 0.324 0.429 0.00 0.365 0.164 0.00 0.00 Maximum 1.51 1.42 2.01 2.08 3.44 2.84 1.89 2.03 1.81 1.96 1.86 1.58 Distolateral Median 0.664 0.680 0.692 0.709 0.665 0.683 0.804 0.829 0.747 0.766 0.716 0.732 Standard Deviation 0.233 1.47 0.386 0.229 0.251 0.291 0.236 0.282 0.217 0.492 0.315 0.368 Minimum 0.426 0.471 0.502 0.346 0.00 0.324 0.514 0.565 0.524 0.00 0.00 0.00 Maximum 1.58 8.25 2.31 1.33 1.56 1.92 1.59 1.65 1.80 2.15 1.55 1.96 Shapiro-wilk test p > 0,05 Friedman test p > 0,05 Shapiro-wilk test p > 0,05 Friedman test p > 0,05 4 DISCUSSION The null hypothesis of this study, which posited that orthognathic surgery (OS) interferes with the bone quality of the mandibular head and its adaptability over time, was rejected. It was observed that the mandibular head remained stable even after OS. In the literature, the impact of OS on the temporomandibular joints (TMJs) has been the subject of analysis in various studies over the last few decades [ 1 , 22 ]. These works seek to understand the factors that influence treatment and its outcomes, with the aim of improving surgical techniques and the treatment process comprehensively [ 23 ]. Due to the nature of OS procedures, significant changes occur in the position of the mandibular head, resulting in morphological changes. In this study, we included CBCT scans of patients diagnosed with Class II and Class III skeletal deformities, who underwent OS for maxillomandibular advancement or maxillary advancement combined with mandibular setback [ 18 ]. Mandibular advancement, performed alone or in conjunction with maxillary procedures, is often employed to improve masticatory function and facial aesthetics in patients [ 24 ]. It is important to note that the chances of bone resorption can increase significantly after mandibular advancement. The extent of mandibular advancement, mandibular counterclockwise rotation, and the surgical technique employed are factors that can considerably influence the final condition of the TMJ tissues [ 25 ]. In the sample of this study, condylar positioning during orthognathic surgery was performed passively. The condyle was positioned in the ideal location, i.e., anteriorly and superiorly in the mandibular fossa. Sudden and forced movements in the proximal segments should be avoided as they may cause damage to ligaments and TMJ structures [ 17 ]. Increased loading can occur in cases with greater advancement or when a counterclockwise rotation of the mandibular plane occurs during surgical mandibular advancement [ 26 ]. Correct positioning allows for early postoperative return to function to enable joint remodeling and adaptation to the new load, as well as accommodation and balance of the suprahyoid musculature (which tends to pull the mandible posteriorly). Another important factor concerns the type of fixation used in mandibular osteotomies; in all cases used for this research, hybrid mandibular fixation was employed, which reduces the risk of condylar torque and its consequent remodeling, and in more extreme cases, even its resorption. Speech therapy and postoperative physiotherapy play an extremely important role [ 27 ]. Patients undergoing orthognathic surgery may present a variety of changes in the TMJ, which has generated controversy regarding whether the procedure can negatively affect this joint [ 25 ]. So far, no study has specifically assessed the effect of orthognathic surgery on patients with Class II and Class III malocclusion on the microstructure of the mandibular head using CT with fractal analysis. This study sought to fill this gap by employing CBCT to evaluate the remodeling capacity of the mandibular head, comparing the periods before and after surgery. CBCT has proven to be an effective technique for assessing bone structure, providing detailed information about cortical edges and the internal configuration of the bone in three distinct dimensions [ 28 ]. The three-dimensional (3D) changes in the position of the mandible, maxilla, or both, resulting from orthognathic surgery, affect not only the TMJ but also the masticatory musculature and surrounding soft tissues (4). These positional changes can morphologically influence the TMJ. Although, in some cases, no change is observed, adaptations and even degenerative alterations in the TMJ can be possible responses to these surgeries [ 24 ]. In the existing literature [ 2 , 29 ], different measurement protocols impact the morphological changes detected in CBCT studies, resulting in diverse interpretations, especially for the subtle changes involved in condylar remodeling. Two approaches have been used to assess condylar remodeling: volumetric measurement of the 3D condylar model and calculation of the distance between surfaces. For a comprehensive and accurate analysis of remodeling, volumetric analysis and measurement between surfaces should be combined [ 29 ]. In this study, fractal analysis was employed to assess trabecular bone density, while cortical bone thickness was measured in millimeters at different points, aiming for a comprehensive evaluation of mandibular head adaptation after orthognathic surgery. Currently, fractal analysis has been widely employed in Dentistry, covering various areas such as the study of systemic diseases affecting the TMJ, bone consolidation around dental implants, and the effects of periodontal disease on bone microstructure [ 8 , 13 , 30 ]. In this study, fractal analysis was used to quantify the complexity of structures, expressed numerically as fractal value (FV). Many studies in the literature calculate FV to assess trabecular bone density and complexity, where higher fractal values indicate greater quality and complexity of the internal bone structure, while lower values may be associated with weaker bone resulting from alterations in internal structure and trabecular configuration [ 31 , 32 ]. The FVs were compared in different reconstructions pre and postoperatively, revealing no statistically significant differences. In other words, the trabecular bone density of the mandibular head remained constant six to eight months after the orthognathic surgery. The same pattern was observed in the cortical thickness of the mandibular head, indicating no changes even after the surgical intervention. Therefore, in this study, orthognathic surgery does not appear to have compromised the quality of the mandibular head bone structure over time. This suggests that the orthognathic surgery technique performed in this sample had a positive impact on the position of the mandibular head. Regarding the follow-up time to observe condylar remodeling, the six-month period seems appropriate for this evaluation [ 33 ]. Several studies have investigated condylar changes within a six-month period following orthognathic surgery [ 34 ]. A minimum interval of six to twelve months post-surgery was established for adequate comparison of mandibular heads, as they exhibit relative stability during this period [ 34 – 36 ]. Further comprehensive and detailed research is recommended regarding rotation and inclination as possible risk factors. Additionally, the importance of long-term analyses is emphasized, especially in studies addressing bone remodeling. The information collected and the quantitative data presented in this study are considered valuable and can serve as a solid foundation for future comparative analyses. Although our results suggest stability in post-surgical bone adaptation, further research is essential for a deeper understanding of these changes and their clinical implications. 5 Conclusion This study concluded that orthognathic surgery for correcting Class II and Class III malocclusions did not have a significant long-term impact on the microstructure of the mandibular head, as evidenced by fractal analysis and cortical thickness measurement. Declarations Funding : No funding was received for conducting this study. Competing interests : All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. Author Contribution : All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Isabela Inoue Kussaba, Beatriz Caio Felipe and Rodrigo Lorenzi Poluha. The first draft of the manuscript was written by Liogi Iwaki Filho, Lilian Cristina Vessoni Iwaki and Mariliani Chicarelli da Silva. All authors commented on previous version of the manuscript. All authors read and approved the final manuscript. Ethics approval declaration : The present retrospective cohort study was approved by the Permanent Committee of Ethics in Research Involving Human Subjects of the State University of Maringá (UEM) (opinion: CAAE: 65405022.2.0000.0104) Consent to publish: The authors affirm that human research participants provided informed consent for publication of the images in Figure(s) 1 and 3. Consent to participate: Informed consent was obtained from all individual participants included in the study. Data availability declaration: The authors confirm that the data supporting the finding of this study are available within the article [and/or its supplementary materials]. If necessary, the data that support the finding of this study are available on request from the corresponding author [Isabela Inoue Kussaba]. The data are not publicly available due to their containing information of research participants. 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Sci Rep 13(1):18183. https://doi.org/10.1038/s41598-023-45407-6 Gulec M, Tassoker M, Ozcan S, Orhan K (2021) Evaluation of the mandibular trabecular bone in patients with bruxism using fractal analysis. Oral Radiol 37(1):36–45. https://doi.org/10.1007/s11282-020-00422-5 Arsan B, Köse TE, Çene E, Özcan İ (2017) Assessment of the trabecular structure of mandibular condyles in patients with temporomandibular disorders using fractal analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 123(3):382–391. https://doi.org/10.1016/j.oooo.2016.11.005 Cuschieri S (2019) The STROBE guidelines. Saudi J Anaesth 13(5):31. https://doi.org/10.4103/sja.SJA_543_18 de Souza Pinto GN, Iwaki Filho L, Previdelli IT dos, Ramos S, Yamashita AL, Stabile AL (2019) Three-dimensional alterations in pharyngeal airspace, soft palate, and hyoid bone of class II and class III patients submitted to bimaxillary orthognathic surgery: A retrospective study. J Cranio-Maxillofacial Surg 47(6):883–894. https://doi.org/10.1016/j.jcms.2019.03.015 Kim YI, Cho BH, Jung YH, Son WS, Park SB (2011) Cone-beam computerized tomography evaluation of condylar changes and stability following two-jaw surgery: Le Fort I osteotomy and mandibular setback surgery with rigid fixation. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 111(6):681–687. https://doi.org/10.1016/j.tripleo.2010.08.001 Araujo A (1999) Cirurgia ortognática. 1 Edição. Livraria Santos Editora Com. Imp. Ltda, São Paulo Yamashita AL, Iwaki Filho L, Leite PCC, Navarro R, de Ramos L, Previdelli AL (2017) Three-dimensional analysis of the pharyngeal airway space and hyoid bone position after orthognathic surgery. J Cranio-Maxillofacial Surg 45(9):1408–1414. https://doi.org/10.1016/j.jcms.2017.06.016 Felipe BC, Iwaki LCV, Silva MC, Mori AA (2022) Análise de fractal do trabeculado do osso alveolar e da neoformação óssea da sutura palatina mediana após expansão rápida de maxila assistida cirurgicamente Güngör E, Yildirim D, Çevik R (2016) Evaluation of osteoporosis in jaw bones using cone beam CT and dual-energy X-ray absorptiometry. J Oral Sci 58(2):185–194. https://doi.org/10.2334/josnusd.15-0609 Mostafa RA, Arnout EA, Abo el- Fotouh MM (2016) Feasibility of cone beam computed tomography radiomorphometric analysis and fractal dimension in assessment of postmenopausal osteoporosis in correlation with dual X-ray absorptiometry. Dentomaxillofacial Radiol 45(7):20160212. https://doi.org/10.1259/dmfr.20160212 Abrahamsson C, Ekberg EC, Henrikson T, Bondemark L (2007) Alterations of Temporomandibular Disorders before and after Orthognathic Surgery. Angle Orthod 77(4):729–734. https://doi.org/10.2319/052906-215 Pachnicz D, Ramos A (2021) Mandibular condyle displacements after orthognathic surgery—an overview of quantitative studies. Quant Imaging Med Surg 11(4):1628–1650. https://doi.org/10.21037/qims-20-677 Zhai Y, Han JJ, Jung S, Kook MS, Park HJ, Oh HK (2020) Changes in the temporomandibular joint clicking and pain disorders after orthognathic surgery: Comparison of orthodontics-first approach and surgery-first approach. PLoS ONE 15(9):e0238494. https://doi.org/10.1371/journal.pone.0238494 Paunonen J, Helminen M, Sipilä K, Peltomäki T (2019) Temporomandibular disorders in Class II malocclusion patients after surgical mandibular advancement treatment as compared to non-treated patients. J Oral Rehabil 46(7):605–610. https://doi.org/10.1111/joor.12790 Aoyama S, Kino K, Kobayashi J, Yoshimasu H, Amagasa T (2005) Clinical evaluation of the temporomandibular joint following orthognathic surgery-Multiple logistic regression analysis. J Med Dent Sci 52:109–114. https://doi.org/10.11480/jmds.520202 Liporaci Junior JLJ, Stoppa P, Ribeiro HT, Borin Neto AJ, Sverzut CE (2007) Reabsorção condilar progressiva da articulação temporomandibular após cirurgia ortognática. Revista Dent Press de Ortodontia e Ortop Facial 12(2):38–48. https://doi.org/10.1590/S1415-54192007000200009 Anderson P, Yong R, Surman T, Rajion Z, Ranjitkar S (2014) Application of three-dimensional computed tomography in craniofacial clinical practice and research. Aust Dent J 59(s1):174–185. https://doi.org/10.1111/adj.12154 Verhelst PJ, Verstraete L, Shaheen E, Shujaat S, Darche V, Jacobs R et al (2020) Three-dimensional cone beam computed tomography analysis protocols for condylar remodelling following orthognathic surgery: a systematic review. Int J Oral Maxillofac Surg 49(2):207–217. https://doi.org/10.1016/j.ijom.2019.05.009 Mishra S, Kumar M, Mishra L, Mohanty R, Nayak R, Das AC et al (2022) Fractal Dimension as a Tool for Assessment of Dental Implant Stability—A Scoping Review. J Clin Med 11(14):4051. https://doi.org/10.3390/jcm11144051 Cavalcante D, de Silva S, de Carvalho PG, Quidute FSR, Kurita ARP, Cid LM (2022) Is jaw fractal dimension a reliable biomarker for osteoporosis screening? A systematic review and meta-analysis of diagnostic test accuracy studies. Dentomaxillofacial Radiol 51(4). https://doi.org/10.1259/dmfr.20210365 Koh KJ, Park HN, Kim KA (2012) Prediction of age-related osteoporosis using fractal analysis on panoramic radiographs. Imaging Sci Dent 42(4):231. https://doi.org/10.5624/isd.2012.42.4.231 Hwang HS, Jiang T, Sun L, Lee KM, Oh MH, Biao Y et al (2019) Condylar head remodeling compensating for condylar head displacement by orthognathic surgery. J Cranio-Maxillofacial Surg 47(3):406–413. https://doi.org/10.1016/j.jcms.2018.11.029 Lee W, Park JU, Pathology O (2002) Oral Radiol Endodontology 94(3):305–309. https://doi.org/10.1067/moe.2002.126452 Kim YJ, Lee Y, Chun YS, Kang N, Kim SJ, Kim M (2014) Condylar Positional Changes Up to 12 Months After Bimaxillary Surgery for Skeletal Class III Malocclusions. J Oral Maxillofac Surg 72(1):145–156. https://doi.org/10.1016/j.joms.2013.07.031 Chen S, Lei J, Wang X, Fu K, yuan, Farzad P, Yi B (2013) Short- and Long-Term Changes of Condylar Position After Bilateral Sagittal Split Ramus Osteotomy for Mandibular Advancement in Combination With Le Fort I Osteotomy Evaluated by Cone-Beam Computed Tomography. J Oral Maxillofac Surg 71(11):1956–1966. https://doi.org/10.1016/j.joms.2013.06.213 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Jul, 2025 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted Editorial decision: Revision requested 27 May, 2025 Reviews received at journal 30 Apr, 2025 Reviewers agreed at journal 25 Apr, 2025 Reviews received at journal 05 Feb, 2025 Reviewers agreed at journal 14 Jan, 2025 Reviewers invited by journal 21 May, 2024 Submission checks completed at journal 16 May, 2024 Editor assigned by journal 16 May, 2024 First submitted to journal 15 May, 2024 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-4426661","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":306989128,"identity":"bafa9522-82a2-4fb9-9566-8f1af2739ba8","order_by":0,"name":"Isabela Inoue Kussaba","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYBACNjAqYOCRAPEYGxjkQPSBBwS1GCC0GIO1JBC0yICBAaYlsQHEwKeFj//wswcfDOxkJGekP/7wc4dd+vywww+BttjJ6TbgsEIizdxwhkEyj7REjplk75nk3I230wyAWpKNzQ7g0sJgJs1jwMwjJ5HDxsDbxpy7cXYCSMuBxG24tPAf/yb9x6AeqCX98ce/bfXphrPTP+DXwpBjJs1gcBjosAQDad62wwny0jkEbJHIKTfsMTjOI9nzxkxa9sxxww3SOQUHEgxw+0W+//i2Bz8qqu0ljgMd9nZHtbz87PTNHz5U2Mnh0oIJDMAqDYhVDra3gRTVo2AUjIJRMBIAAPTfW1SLQD6+AAAAAElFTkSuQmCC","orcid":"","institution":"State University of Maringá","correspondingAuthor":true,"prefix":"","firstName":"Isabela","middleName":"Inoue","lastName":"Kussaba","suffix":""},{"id":306989129,"identity":"63e387c8-7bfa-4a34-8337-09ea879c25f3","order_by":1,"name":"Beatriz Caio Felipe","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Beatriz","middleName":"Caio","lastName":"Felipe","suffix":""},{"id":306989130,"identity":"1f54cc90-5d66-45f0-9ea0-48bc577758e3","order_by":2,"name":"Rodrigo Lorenzi Poluha","email":"","orcid":"","institution":"State University of Maringá","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"Lorenzi","lastName":"Poluha","suffix":""},{"id":306989131,"identity":"5290ddab-8b35-49a0-8134-2e7351867a33","order_by":3,"name":"Liogi Iwaki Filho","email":"","orcid":"","institution":"State University of Maringá","correspondingAuthor":false,"prefix":"","firstName":"Liogi","middleName":"Iwaki","lastName":"Filho","suffix":""},{"id":306989132,"identity":"72e96e46-a17e-4657-b995-7e5f190e71de","order_by":4,"name":"Mariliani Chicarelli da Silva","email":"","orcid":"","institution":"State University of Maringá","correspondingAuthor":false,"prefix":"","firstName":"Mariliani","middleName":"Chicarelli da","lastName":"Silva","suffix":""},{"id":306989134,"identity":"e3c46a22-686c-4342-b525-bba464fc415d","order_by":5,"name":"Lilian Cristina Vessoni Iwaki","email":"","orcid":"","institution":"State University of Maringá","correspondingAuthor":false,"prefix":"","firstName":"Lilian","middleName":"Cristina Vessoni","lastName":"Iwaki","suffix":""}],"badges":[],"createdAt":"2024-05-15 17:22:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4426661/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4426661/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10006-025-01430-7","type":"published","date":"2025-07-17T16:05:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57450137,"identity":"bb044415-c28f-4de6-ba46-e65904144db1","added_by":"auto","created_at":"2024-05-30 20:16:20","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34170,"visible":true,"origin":"","legend":"\u003cp\u003eA: ROI selection in the coronal reconstruction. B: ROI selection in the sagittal reconstruction.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4426661/v1/04e0a33532571e9725874360.jpg"},{"id":57450437,"identity":"5261ca4d-23b4-4703-94b6-5cfaf7fb80a4","added_by":"auto","created_at":"2024-05-30 20:24:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":53492,"visible":true,"origin":"","legend":"\u003cp\u003eFractal analysis according to the method of White and Rudolph, 1999. Protocol used: (A) original image; (B) application of Gaussian blur filter; (C) subtraction of the first image and addition of gray values at 128 pixels; (D) image binarization; (E) result after image skeletonization.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4426661/v1/873354c7f0fdec2b473afd60.png"},{"id":57450138,"identity":"56e71e89-902e-4bf7-b979-bb0820e16ddc","added_by":"auto","created_at":"2024-05-30 20:16:20","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":54057,"visible":true,"origin":"","legend":"\u003cp\u003eA:\u003cstrong\u003e \u003c/strong\u003eMeasurements performed in the axial reconstruction. B: Measurement performed in the sagittal reconstruction of the bone cortex.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4426661/v1/057a1c60afaac01e4dbd28ed.jpg"},{"id":88507198,"identity":"093706d9-276d-4430-94d1-db2dda139b4c","added_by":"auto","created_at":"2025-08-07 07:37:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1111481,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4426661/v1/15017b60-d64f-4cfd-ba78-9b92fd993c2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fractal analysis of the mandibular ramus in class II and III patients undergoing orthognathic surgery: Retrospective study trough Cone-beam Computed Tomography","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eSevere malocclusions accompanied by skeletal discrepancies can result in a variety of functional and aesthetic alterations. The approach to correcting these deformities involves careful integration of orthodontic treatment and orthognathic surgery (OS). Orthognathic surgical procedures are traditionally performed following preoperative orthodontic preparation aimed at leveling and decompensating the dental arches. Subsequently, surgery is followed by postoperative orthodontic therapy, aiming to stabilize surgical outcomes and improve occlusal relationship [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, in OS, one of the central challenges is maintaining the proper position of the mandibular ramus during osteosynthesis. This is crucial because the postoperative condylar position is directly linked to morphological changes in the temporomandibular joint (TMJ), playing a critical role in surgical stability. Thus, preserving the physiological position of the mandibular ramus and reducing intraoperative condylar movement continue to be the gold standard for minimizing postoperative TMJ symptoms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBilateral sagittal osteotomy stands out as the most used surgical technique to correct skeletal class II and III discrepancies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Three-dimensional (3D) changes in the position of the mandible, maxilla, or both, resulting from OS, impact not only the TMJ but also the masticatory musculature, surrounding soft tissues, and consequently, the signs and symptoms of temporomandibular disorders (TMDs) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Mandibular advancement tends to result in an anterior position of the mandibular ramus in the mandibular fossa, inducing the entire mandibular ramus/temporomandibular disc complex to follow this movement for a period.\u003c/p\u003e \u003cp\u003eAdditionally, this new anterior mandibular posture often demands adaptation of the surrounding soft tissue, with significant implications for muscle fibers. It is evident that such therapeutic approach often triggers a series of changes in the stomatognathic system. The natural adaptive capacity of the TMJs, when exceeded, can result in condylar remodeling [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, despite the diversity of observed alterations, little is known about the true impact of protrusion as a predisposing, initiating, or perpetuating factor of TMDs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the literature, no study to date has evaluated the effect of OS in Class II and Class III malocclusion patients on the microstructure of the mandibular ramus through computed tomography (CT) using fractal analysis.\u003c/p\u003e \u003cp\u003eThree-dimensional diagnostic techniques offer enhanced precision in image acquisition. Cone beam computed tomography (CBCT) provides high-resolution images for the evaluation and quantification of facial bone tissues in real dimensions (1:1 ratio), eliminating magnification or distortion and thus offering greater anatomical precision. Additionally, it highlights cost reduction, lower radiation exposure, and shorter acquisition time compared to helical CT [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. CBCT enables detailed evaluation of cortical bone, condylar position, mandibular fossa, articular eminence, and joint spaces. Its ability to provide high-quality images makes it suitable for detecting progressive bone changes such as osteophyte formation, erosion, condylar flattening, sclerosis, concavity, and subcortical cysts [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, CBCT is widely used in clinical diagnosis, with volumetric analysis from this technique considered reliable and precise in evaluating changes in the mandibular ramus [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Dentistry, fractal analysis was first used in 1999 to evaluate changes in the pattern of trabecular bone in the mandible and maxilla of patients with osteoporosis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Since then, it has been a method used to assess changes in trabecular bone. Fractal dimension (FD), obtained from radiographs or tomographs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], is a measure that allows interpretation of the microstructure of trabecular bone [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Higher FD values are associated with a complex bone structure, characterized by denser and less porous trabecular architecture [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Since direct visualization of degenerative changes in the bony components of the temporomandibular joint (TMJ) is not always practical, fractal analysis emerges as an effective approach to overcome this limitation.\u003c/p\u003e \u003cp\u003eAssessing the bone remodeling of the mandibular ramus post-OS is essential for monitoring joint health evolution and developing effective treatment strategies. Understanding changes in condylar bone structure over time after OS is important for precise clinical monitoring and for anticipating and correcting potential complications, aiming to optimize clinical outcomes and patient quality of life. Thus, the aim of the present study is to perform fractal analysis of the mandibular ramus in Class II and Class III patients undergoing OS, analyzing CBCT scans one month before OS (T0), one month after OS (T1), and six to eight months after OS (T2). The null hypothesis of this study posits that OS does not interfere with the bone quality of the mandibular ramus and its capacity for adaptation over time.\u003c/p\u003e"},{"header":"2 Methodology","content":"\u003cp\u003eThe present retrospective cohort study was approved by the Permanent Committee of Ethics in Research Involving Human Subjects of the State University of Maring\u0026aacute; (UEM) (opinion: CAAE: 65405022.2.0000.0104) and developed following the recommendations of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [14]. Due to the retrospective nature of this study, the Committee did not require the signing of informed consent forms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample was conveniently selected, comprising 30 CBCT scans of Class II patients (undergoing maxillomandibular advancement) and another 32 of Class III patients (undergoing maxillary advancement and mandibular setback surgery) [15]. All patients underwent OS and were operated on by the team from the Residency Program in Oral and Maxillofacial Surgery and Traumatology at UEM.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Inclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor this study, we included CBCT scans of patients over 18 years of age, of both sexes, diagnosed with skeletal Class II and Class III malocclusions according to Angle classification, who underwent OS. Patients with craniofacial syndromes, previous alterations in the temporomandibular joint (TMJ), or incomplete documentation were excluded. From this selection, five patients were excluded: two due to a condition called retrusive mandibular ramus, two due to incomplete documentation, and one due to having a craniofacial syndrome, resulting in a final sample of 57 patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Surgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMandibular advancement and setback were performed using bilateral sagittal split ramus osteotomy; maxillary osteotomies were performed using the Le Fort I osteotomy technique [15,16]. The sagittal split ramus osteotomy is the most used procedure in orthognathic surgery. Its versatility is due to its design offering a wide area of contact between the bone segments, which provides better healing and greater stability. The fixation technique for the mandibular osteotomy was the hybrid technique, which reduces the risk of condylar torque and subsequent resorption. On the other hand, the Le Fort I osteotomy is indicated for moving the maxilla in three spatial planes, as well as leveling dental arches, modifying arch shapes, and coordinating transverse discrepancies between the maxillary and mandibular arches [17].\u003c/p\u003e\n\u003cp\u003eCBCT scans were collected from April 2014 to February 2022. Fractal analysis of the images was performed at three different time points: one month before OS (T0), one month after the intervention (T1), and between six and eight months after OS (T2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Image Acquisition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CBCT scans were performed at the Laboratory of Images in Clinical Research (LIPC) of the Health Technology Center (CTS), part of the Complex of Support Centers for Research (COMCAP), located in the Department of Dentistry at the State University of Maring\u0026aacute; (DOD-UEM). All images were captured by a specialist in Dental Radiology and Imaging, using the i-CAT Next Generation\u0026reg; equipment (Imaging Sciences International, Hatfield, PA, USA). During the procedure, patients were instructed to sit still, adopt a natural head position, breathe calmly, and keep their tongue and lips at rest [18]. Chin and head support were removed during image acquisition to prevent soft tissue alterations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Evaluators and Image Region Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted by one evaluator using ImageJ software (version 2.0.0), a public domain tool provided by the National Institutes of Health, Bethesda, Md, USA (https://imagej.nih.gov/ij). According to the guidelines of the Examiner Calibration Manual published by the Brazilian Ministry of Health in 2001, the evaluator underwent a calibration and training process. The training included a detailed theoretical discussion of all criteria used in the evaluation. Then, a practical training session was conducted, during which the examiner analyzed the same exams at different times. Possible discrepancies in the results were discussed to reach a consensus on the rules and criteria for CBCT evaluation. Finally, effective calibration was performed by calculating intra-rater agreement using the Intraclass Correlation Coefficient (ICC) [19]. All CBCT scans were analyzed twice, with a 15-day interval, by the same examiner.\u003c/p\u003e\n\u003cp\u003eThe fractal analysis was performed on a computer equipped with the Microsoft Windows XP Professional SP-2 operating system (Microsoft Corp., Redmond, WA, USA), Intel\u0026reg; CoreTM 2 Duo 1.86 GHz-6300 processor (Intel Corporation, USA), NVIDIA GeForce 6200 Turbo Cache graphics card (NVIDIA Corporation, USA), and EIZO - S2000 FlexScan monitor, resolution of 1600 \u0026times; 1200 pixels (EIZO Nanao Corporation, Hakusan, Japan).\u003c/p\u003e\n\u003cp\u003eThe analyses were conducted on coronal and sagittal reconstructions. For this purpose, Regions of Interest (ROIs) were selected for each patient and evaluated region. Axial sections with a slice thickness of 0.3 mm were examined, and a coronal image was selected at the widest part in the mediolateral dimension of the mandibular head. Similarly, coronal sections with the same slice thickness were examined, and the sagittal image passing through the middle of the mandibular head was chosen. Coronal and sagittal images of all mandibular heads underwent fractal analysis, as described by KOCAK et al., in 2021 [8,20]. This method was performed on each patient on both right and left mandibular heads.\u003c/p\u003e\n\u003cp\u003eThe CBCT scans were opened in ImageJ software. In each CBCT image in the coronal reconstruction, a round ROI of 25x25 pixels was selected in the region of the trabecular bone of the mandibular head (Figure 01). In sagittal reconstructions, a ROI of 20x20 pixels was chosen [21].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 01. \u003c/strong\u003eA: ROI selection in the coronal reconstruction. B: ROI selection in the sagittal reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Fractal evaluation of condylar bone trabeculation in Class II and Class III patients undergoing orthognathic surgery.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFractal evaluation of condylar bone trabeculation in Class II and Class III patients undergoing orthognathic surgery followed the steps described by White \u0026amp; Rudolph, 1999 [10], using ImageJ software. The process comprised the following steps (Figure 02):\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eDuplication of the original image:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cul\u003e\n\u003cli\u003eCreation of a copy of the original image.\u003c/li\u003e\n\u003c/ul\u003e\n\u003col start=\"2\"\u003e\n\u003cli\u003eApplication of Gaussian filter:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cul\u003e\n\u003cli\u003eRemoval of low and medium-scale structures, retaining Only significant density variations, i.e. high contrast.\u003c/li\u003e\n\u003c/ul\u003e\n\u003col start=\"3\"\u003e\n\u003cli\u003eSubtraction and Addition of gray value:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cul\u003e\n\u003cli\u003eSubtraction of the second image from the original.\u003c/li\u003e\n\u003cli\u003eAddition of a gray value of 128 to each pixel, generating an image with an average gray value of 128, highlighting specific individual brightness variations, such as the bone trabeculae of the mandibular head.\u003c/li\u003e\n\u003c/ul\u003e\n\u003col start=\"4\"\u003e\n\u003cli\u003eBinary Image Transformation:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cul\u003e\n\u003cli\u003eImage segmentation to visually highlight structures radiographically similar to bone trabeculae.\u003c/li\u003e\n\u003c/ul\u003e\n\u003col start=\"5\"\u003e\n\u003cli\u003eErozion and Dilation:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cul\u003e\n\u003cli\u003eProcess for noise reduction.\u003c/li\u003e\n\u003c/ul\u003e\n\u003col start=\"6\"\u003e\n\u003cli\u003eSkeletonization:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cul\u003e\n\u003cli\u003eErosion of the image until only the central line of pixels remains.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 02. \u003c/strong\u003eFractal analysis according to the method of White and Rudolph, 1999. Protocol used: (A) original image; (B) application of Gaussian blur filter; (C) subtraction of the first image and addition of gray values at 128 pixels; (D) image binarization; (E) result after image skeletonization.\u003c/p\u003e\n\u003cp\u003eAfter processing, fractal analysis was calculated using the box counting method by the \"Fractal Box Count\" function of the ImageJ software [19].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7 Evaluation of condylar bone cortex in Class II and Class III patients undergoing orthognathic surgery.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation of condylar bone cortex in Class II and Class III patients undergoing orthognathic surgery was measured in millimeters on two different tomographic reconstructions positioned in the center of the mandibular head: sagittal and axial reconstructions. In the sagittal reconstruction, the cortical thickness in millimeters was measured at the top region of the mandibular head, while in the axial reconstruction, the cortical thickness was measured at four different points: anterior, posterior, mediolateral, and distolateral. These measurements were performed using Imaging Studio software (Figure 03).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 03. \u003c/strong\u003eA: Measurements performed in the axial reconstruction. B: Measurement performed in the sagittal reconstruction of the bone cortex.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8 Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, we adopted a statistical design that includes the evaluation of intra-rater agreement, using the Intraclass Correlation Coefficient (ICC). For all statistical analyses, we used Jamovi software, an open-source statistical platform that offers a wide range of tools for data analysis (available at www.jamovi.org). Initially, the data were subjected to descriptive analysis. To check the normality of the data distribution, we employed the Shapiro-Wilk test, setting p\u0026lt;0.05 as the threshold for significance. We proceeded with the statistical comparison of the values obtained in fractal evaluations and cortical thickness measurements. For this purpose, we analyzed images of the same regions, both in preoperative and postoperative periods, using the Friedman test. This test was chosen for its suitability in analyzing differences within related groups when the data do not follow a normal distribution. We adopted p\u0026lt;0.05 as the criterion for determining the statistical significance of these comparisons.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant Characteristics: Age and Gender\u003c/h2\u003e \u003cp\u003eThe sample in this study comprised a total of 57 patients, with 27 classified as Class II and 30 as Class III. In Class II, there were 22 female and 5 male patients, with ages ranging from 19 to 49 years. However, in Class III, consisting of 30 patients, the distribution was 16 female and 14 male patients, with ages ranging from 18 to 44 years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Fractal Analysis\u003c/h2\u003e \u003cp\u003eThe fractal analysis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e01\u003c/span\u003e) provided a detailed approach to fractal values, presenting medians, standard deviations, minimum and maximum values at different time points (pre- and post-operative) of images from the same region. Upon examining the different periods (T0, T1, and T2) of patient groups from Classes II and III, no statistically significant differences were identified (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Cortical Thickness\u003c/h2\u003e \u003cp\u003eThe evaluation of cortical thickness (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e02\u003c/span\u003e) was conducted, and no statistically significant differences were observed for both Class II and Class III patients when comparing different pre- and post-operative time points of images from the same region (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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 01\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive analysis of fractal value for Class II and Class III patients in preoperative and postoperative periods.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\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 \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\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eClass II\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eClass III\u003c/p\u003e \u003c/th\u003e \u003c/tr\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\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\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\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eRIGHT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCORONAL RECONSTRUCTION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0598\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0712\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.203\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSAGITAL RECONSTRUCTION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.476\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.14\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\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eShapiro-wilk test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003cp\u003eFriedman test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eShapiro-wilk test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003cp\u003eFriedman test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eLEFT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCORONAL RECONSTRUCTION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0466\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSAGITAL RECONSTRUCTION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1,09\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\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eShapiro-wilk test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003cp\u003eFriedman test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eShapiro-wilk test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003cp\u003eFriedman test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\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 02\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive analysis of cortical thickness (mm) for Class II and Class III patients in preoperative and postoperative periods.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"16\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\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\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e \u003cp\u003eRIGHT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c16\" namest=\"c11\"\u003e \u003cp\u003eLEFT\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\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\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eClass II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eClass III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003eClass II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c16\" namest=\"c14\"\u003e \u003cp\u003eClass III\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\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eT2\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\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSAGITAL RECONSTRUCTION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.842\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.825\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.423\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"15\" rowspan=\"16\"\u003e \u003cp\u003eAXIAL RECONSTRUCION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.950\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.784\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.683\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.653\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediolateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.830\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.928\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.780\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.788\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.451\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistolateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.680\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.709\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.683\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.565\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1.96\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\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c9\" namest=\"c4\"\u003e \u003cp\u003eShapiro-wilk test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003cp\u003eFriedman test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c16\" namest=\"c11\"\u003e \u003cp\u003eShapiro-wilk test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003cp\u003eFriedman test p\u0026thinsp;\u0026gt;\u0026thinsp;0,05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 DISCUSSION","content":"\u003cp\u003eThe null hypothesis of this study, which posited that orthognathic surgery (OS) interferes with the bone quality of the mandibular head and its adaptability over time, was rejected. It was observed that the mandibular head remained stable even after OS. In the literature, the impact of OS on the temporomandibular joints (TMJs) has been the subject of analysis in various studies over the last few decades [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These works seek to understand the factors that influence treatment and its outcomes, with the aim of improving surgical techniques and the treatment process comprehensively [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Due to the nature of OS procedures, significant changes occur in the position of the mandibular head, resulting in morphological changes.\u003c/p\u003e \u003cp\u003eIn this study, we included CBCT scans of patients diagnosed with Class II and Class III skeletal deformities, who underwent OS for maxillomandibular advancement or maxillary advancement combined with mandibular setback [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Mandibular advancement, performed alone or in conjunction with maxillary procedures, is often employed to improve masticatory function and facial aesthetics in patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It is important to note that the chances of bone resorption can increase significantly after mandibular advancement. The extent of mandibular advancement, mandibular counterclockwise rotation, and the surgical technique employed are factors that can considerably influence the final condition of the TMJ tissues [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the sample of this study, condylar positioning during orthognathic surgery was performed passively. The condyle was positioned in the ideal location, i.e., anteriorly and superiorly in the mandibular fossa. Sudden and forced movements in the proximal segments should be avoided as they may cause damage to ligaments and TMJ structures [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Increased loading can occur in cases with greater advancement or when a counterclockwise rotation of the mandibular plane occurs during surgical mandibular advancement [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Correct positioning allows for early postoperative return to function to enable joint remodeling and adaptation to the new load, as well as accommodation and balance of the suprahyoid musculature (which tends to pull the mandible posteriorly). Another important factor concerns the type of fixation used in mandibular osteotomies; in all cases used for this research, hybrid mandibular fixation was employed, which reduces the risk of condylar torque and its consequent remodeling, and in more extreme cases, even its resorption. Speech therapy and postoperative physiotherapy play an extremely important role [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients undergoing orthognathic surgery may present a variety of changes in the TMJ, which has generated controversy regarding whether the procedure can negatively affect this joint [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. So far, no study has specifically assessed the effect of orthognathic surgery on patients with Class II and Class III malocclusion on the microstructure of the mandibular head using CT with fractal analysis. This study sought to fill this gap by employing CBCT to evaluate the remodeling capacity of the mandibular head, comparing the periods before and after surgery. CBCT has proven to be an effective technique for assessing bone structure, providing detailed information about cortical edges and the internal configuration of the bone in three distinct dimensions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe three-dimensional (3D) changes in the position of the mandible, maxilla, or both, resulting from orthognathic surgery, affect not only the TMJ but also the masticatory musculature and surrounding soft tissues (4). These positional changes can morphologically influence the TMJ. Although, in some cases, no change is observed, adaptations and even degenerative alterations in the TMJ can be possible responses to these surgeries [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the existing literature [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], different measurement protocols impact the morphological changes detected in CBCT studies, resulting in diverse interpretations, especially for the subtle changes involved in condylar remodeling. Two approaches have been used to assess condylar remodeling: volumetric measurement of the 3D condylar model and calculation of the distance between surfaces. For a comprehensive and accurate analysis of remodeling, volumetric analysis and measurement between surfaces should be combined [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In this study, fractal analysis was employed to assess trabecular bone density, while cortical bone thickness was measured in millimeters at different points, aiming for a comprehensive evaluation of mandibular head adaptation after orthognathic surgery.\u003c/p\u003e \u003cp\u003eCurrently, fractal analysis has been widely employed in Dentistry, covering various areas such as the study of systemic diseases affecting the TMJ, bone consolidation around dental implants, and the effects of periodontal disease on bone microstructure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In this study, fractal analysis was used to quantify the complexity of structures, expressed numerically as fractal value (FV). Many studies in the literature calculate FV to assess trabecular bone density and complexity, where higher fractal values indicate greater quality and complexity of the internal bone structure, while lower values may be associated with weaker bone resulting from alterations in internal structure and trabecular configuration [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe FVs were compared in different reconstructions pre and postoperatively, revealing no statistically significant differences. In other words, the trabecular bone density of the mandibular head remained constant six to eight months after the orthognathic surgery. The same pattern was observed in the cortical thickness of the mandibular head, indicating no changes even after the surgical intervention. Therefore, in this study, orthognathic surgery does not appear to have compromised the quality of the mandibular head bone structure over time. This suggests that the orthognathic surgery technique performed in this sample had a positive impact on the position of the mandibular head.\u003c/p\u003e \u003cp\u003eRegarding the follow-up time to observe condylar remodeling, the six-month period seems appropriate for this evaluation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Several studies have investigated condylar changes within a six-month period following orthognathic surgery [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. A minimum interval of six to twelve months post-surgery was established for adequate comparison of mandibular heads, as they exhibit relative stability during this period [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurther comprehensive and detailed research is recommended regarding rotation and inclination as possible risk factors. Additionally, the importance of long-term analyses is emphasized, especially in studies addressing bone remodeling. The information collected and the quantitative data presented in this study are considered valuable and can serve as a solid foundation for future comparative analyses. Although our results suggest stability in post-surgical bone adaptation, further research is essential for a deeper understanding of these changes and their clinical implications.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study concluded that orthognathic surgery for correcting Class II and Class III malocclusions did not have a significant long-term impact on the microstructure of the mandibular head, as evidenced by fractal analysis and cortical thickness measurement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:\u0026nbsp;No funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e:\u0026nbsp;\u003cem\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Isabela Inoue Kussaba, Beatriz Caio Felipe and Rodrigo Lorenzi Poluha. The first draft of the manuscript was written by Liogi Iwaki Filho, Lilian Cristina Vessoni Iwaki and Mariliani Chicarelli da Silva. All authors commented on previous version of the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval declaration\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003eThe present retrospective cohort study was approved by the Permanent Committee of Ethics in Research Involving Human Subjects of the State University of Maring\u0026aacute; (UEM) (opinion: CAAE: 65405022.2.0000.0104)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eThe authors affirm that human research participants provided informed consent for publication of the images in Figure(s) 1 and 3.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/em\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability declaration:\u0026nbsp;\u003c/strong\u003eThe authors confirm that the data supporting the finding of this study are available within the article [and/or its supplementary materials]. If necessary, the data that support the finding of this study are available on request from the corresponding author [Isabela Inoue Kussaba]. The data are not publicly available due to their containing information of research participants.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePelo S, Saponaro G, De Angelis P, Gasparini G, Garagiola U, Moro A (2018) Effect of Surgery First Orthognathic Approach on the Temporomandibular Joint. 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J Oral Maxillofac Surg 71(11):1956\u0026ndash;1966. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.joms.2013.06.213\u003c/span\u003e\u003cspan address=\"10.1016/j.joms.2013.06.213\" 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":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Fractal analysis, Orthognathic surgery, Temporomandibular joint, Cone beam computed tomography, Three-dimensional analysis","lastPublishedDoi":"10.21203/rs.3.rs-4426661/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4426661/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eOne of the challenges of orthognathic surgery (OS) is maintaining condylar position during osteosynthesis. It is believed that the post-surgical condylar position is related to postoperative morphological changes in the temporomandibular joint (TMJ), as well as surgical stability. Therefore, the aim of this study is to perform fractal analysis of the mandibular ramus in class II and class III patients undergoing OS, analyzing cone beam computed tomography (CBCT) images one month before surgery (T0), one month after surgery (T1), and six to eight months after surgery (T2). Fractal analysis was performed on coronal and sagittal reconstructions. Regions of interest (ROIs) were selected for each patient and evaluated region. The ROIs underwent a processing method described by White \u0026amp; Rudolph in 1999. After processing, fractal analysis calculation was performed using the box-counting method by the \"Fractal Box Count\" function of the ImageJ software. When examining the different periods (T0, T1, and T2) among class II and class III patients, no statistically significant differences were identified (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This finding suggests stability in the fractal characteristics of the analyzed region, regardless of skeletal class. Thus, OS for correction of Class II and Class III malocclusions did not demonstrate a significant impact on the microstructure of the mandibular ramus over time.\u003c/p\u003e","manuscriptTitle":"Fractal analysis of the mandibular ramus in class II and III patients undergoing orthognathic surgery: Retrospective study trough Cone-beam Computed Tomography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-30 20:16:16","doi":"10.21203/rs.3.rs-4426661/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-27T11:35:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-30T16:27:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270597453018409201536791061906725011874","date":"2025-04-25T07:37:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-05T17:19:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259828803525601264758666440998757990384","date":"2025-01-14T12:28:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-22T00:13:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-16T22:59:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-16T22:59:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Oral and Maxillofacial Surgery","date":"2024-05-15T17:20:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"34cdb638-bc82-49e3-8dff-f5d3e9c81c3b","owner":[],"postedDate":"May 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T07:29:33+00:00","versionOfRecord":{"articleIdentity":"rs-4426661","link":"https://doi.org/10.1007/s10006-025-01430-7","journal":{"identity":"oral-and-maxillofacial-surgery","isVorOnly":false,"title":"Oral and Maxillofacial Surgery"},"publishedOn":"2025-07-17 16:05:27","publishedOnDateReadable":"July 17th, 2025"},"versionCreatedAt":"2024-05-30 20:16:16","video":"","vorDoi":"10.1007/s10006-025-01430-7","vorDoiUrl":"https://doi.org/10.1007/s10006-025-01430-7","workflowStages":[]},"version":"v1","identity":"rs-4426661","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4426661","identity":"rs-4426661","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}