Reliability and Reproducibility of CBCT Assessment of craniomaxillary Changes Before and After Treatment for Class III Growing Patients – An convenient and intuitively Way for Evaluation

Reliability and Reproducibility of CBCT Assessment of craniomaxillary Changes Before and After Treatment for Class III Growing Patients – An convenient and intuitively Way for Evaluation | 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 Reliability and Reproducibility of CBCT Assessment of craniomaxillary Changes Before and After Treatment for Class III Growing Patients – An convenient and intuitively Way for Evaluation XiaoYing Hu, Shun Pan Cheung Gary, YiYang Zhang, RuoNan Sun, Fusheng Dong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4890919/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Oct, 2025 Read the published version in BMC Pediatrics → Version 1 posted 4 You are reading this latest preprint version Abstract Objectives To evaluate reliability and reproducibility of 3-dimensional (3D) assessment of maxillary protraction treatment using voxel-based superimposition of cone-beam computed tomography (CBCT) models of the anterior cranial base in growing patients with skeletal class III malocclusion. Methods CBCT scans were performed before and after maxillary protraction treatment for Class III malocclusion. Three observers independently constructed 162(27*2*3) 3D virtual models from CBCT scans, which had been reoriented 3D models before treatment to natural head posture, of 27 patients in software. The anterior cranial base was used to register the 3D models pre- and port- treatment. Three observers independently identified 9 landmarks(Including those in the contralateral side)and recorded in three-dimensional coordinates in the 3D models. Each observers performed this three times on the pre- and post-treatment model. The mean value of the 3 sets of coordinates at different times was taken as the coordinates for each landmark. The intraobserver reliability and inter-observer reproducibility of the method for craniomaxillary changes were analyzed. Results The ICCs was > 0.90 for 25 (92.6%) out of the total 27 intraobserver assessments. The precision of the measurement method was within 0.3 mm in 21 (77.8%) cases. The interobserver reproducibility errors were < 0.3 mm in 21 of the 27 cases (77.8%). Conclusions The reliability and reproducibility of the method for assessment of maxillary protraction treatment in growing patients with skeletal Class Ⅲ malocclusion were judged to be excellent. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Skeletal Class III malocclusions are the abnormal relationship between maxilla and mandible due to uneven growth of the two bony structures. About 42–63% of patients belong to the maxillary hypoplasia with the mandible being of normal size or slight prognathic type 1 . Maxillary protraction is recommended for such skeletal Class III patients with maxillary deficiency. Traditionally the cephalograms pre-and post- treatment were compared by superimposing stable structures such as the anterior cranial base, to evaluate the effect of maxillary protraction and maxillofacial changes 2 , 3 . However, the simple sagittal assessments using 2-dimensional (2D) lateral cephalogram are prone to errors where accurate determination of some landmarks is concerned, because of failure to the anatomic structures 4 there. Also,as patients with skeletal malocclusion often are associated with facial asymmetry 5 , 2D assessment cannot be accurate or reliable. With the advent of imaging technology, cone-beam computed tomography (CBCT) has been preferred as the method of choice for maxillofacial imaging,and as a valuable tool for orthodontic treatment planning and clinical research. CBCT would provide a comprehensive analysis of any three-dimensional (3D) changes in the size, shape and position of the maxillofacial structures 6 .In particular, it affords a more accurate assessment of the labiopalatal direction and the contact relationship between adjacent teeth ,when compared to 2D radiography 7 . Superimposition of virtual models is necessary for 3D measurements, a process that is much more complex than with 2D images. Identification of landmarks the first step, which is also prone to errors. Despite the difficulty, some researchers have made progress and achieved good reliability 8 – 11 . For instance, Lagravère and coworkers 12 put forward an ELSA standardized coordinate system based on 4 landmarks: (i) midpoint between the geometric centers of the foramina spinosum; (ii & iii) the right (rSLEAM) and left superior-lateral border of the external auditory meatus (lSLEAM); and (iv) the mid-dorsum foramen magnum (MDFM). However, because the skull base is situated far away from the face, any discrepancy are amplified when the craniomaxillary features were mapped to the coordinate system. Later, the error is the 3D superposition measurements will be coamplified,which can become clinically significant. Studying the growth of the craniomaxillary structure relies on measurements made to stable locations in the skul l , such as that anterior cranial base 13 . The cribriform ethmoid plate growth ceased by the age of 2.That is, the pubertal growth spur has much less pronounced effect on the anterior cranial base 14 . With different methodologies (longitudinal cephalometry 15 , histology 14 and dry-skull measurements 16 ), three groups of researchers reported that the sphenoethmoid synchondrosis growth stand-by age 7. Therefore, the pre-sphenoid region (the plane surface on the sphenoid bone, in front of sella turcica) ,which is considered stable after 7 years of age 17 , were noted as stable in craniomaxillary region of growing individuals. They may then be used as stable reference, as well as treatment changes. Voxel-based registration of changes with 3D CBCT images has been used in the past few years to evaluate overall facial changes relative to the cranial base 18 . But then, regional craniomaxillary registrations were still controversial. This present study, aimed to evaluate the 3-dimensional craniomaxillary changes in growing patients, who had received orthodontic treatment for Class III malocclusion, and to examine the intraobserver reliability and inter-observer reproducibility of a voxel-based superimposition method. Materials and methods Corresponding pairs of pre- and post-treatment CBCT scans of 27 children, aged 8–11 years before treatment, who had received protraction therapy for their Class III malocclusion at the Department of Orthodontics of the University of Hong Kong-Shenzhen Hospital were included in this study. All patients or their parents gave consent to participate in this study, after hearing a thorough explanation of the research objectives and procedures. The two scans were taken on average 24 to 26 months apart. The scan was included in the analysis based on : cervical vertebral maturation (CS1-CS3); clear and legible 3D images; Class III malocclusion The Exclusion criteria were: discernible craniofacial asymmetry; discernible mandibular asymmetry; temporomandibular joint disorders; history of maxillofacial trauma or surgery in the region; some systemic disease; and previous orthodontic treatment. The study protocol was approved by the Medical Ethics Commission of the University of Hong Kong-Shenzhen Hospital. The parameters of the CBCT machine (Dental Volumetric Tomograph, KaVo 3D eXam, Imaging Sciences International LLC, Hatfield, PA, USA) were set at 120 kVp, 18.54mA, 23 x 17 cm field of view, 0.3 mm voxel size, and scan time of 8.9 s. Data were exported in DICOM format into a 3D imaging software (InvivoDental software 5.1.3, Anatomage Inc, San Jose, USA), in which a virtual model of the patient was created in a 3D coordinate system. The position and orientation of the 3D model in the coordinate system depended on the head position of the patient when the CBCT scanned. In the "section" module, using axial, coronal, and sagittal views on the left side, the 3D virtual model on the right side was oriented: in the lateral view, bilateral structures, such as the orbits, external auditory canals and other structures as much as possible overlap, and the Frank-fort horizontal plane was oriented horizontally Figure 1 . The software offered a “superimposition” module to achieve fully automated voxel-based superimposition of the pre- and post-treatment scan, some stable anatomical area had to be defined first. This was done by clicking on the "voxel registration" button, which called up 3 boxes in the sagittal, coronal and axial view for the observer to select the stable region to guide the superimposition. The boxes were used to select the anatomical structures 19 of the anterior cranial base in the 3D models Figure 2 . After clicking on the "start" button and the automatic voxel-based superimposition of the 3D images began. Stable reference structure that guided the superimposition.The whole process of registration and superimposition took approximately 3 minutes. A total of 9 landmarks (or 6 in total, if the left and right were considered as contributing to one landmark) and defined criteria were established for each landmark. A total of 9 landmarks were located by each observer independently on every surface-rendered 3D model Table 1 and Figure 3 . To identify the landmarks, the observer would navigate to any (sagittal, coronal or axial) view and select the most appropriate slice in that view for registration. The three-dimensional coordinates of each landmark were then automatically recorded by the software. For those landmarks that might be difficult to define in a special view, the observer could call up the surface-rendered model to assist with the localization Figure 4 . Three observers (an orthodontist, an orthodontics master, and a dental radiologist) were trained and calibrated to complete the entire superimposing measurement process using a set of 30 CBCT scans not included in this study. Then, the 3 observers worked independently throughout, to define the 9 anatomical landmarks Table 1 in the superimposed CBCT volume (from pre- and post treatment for the same patient), as described above.The X, Y and Z coordinate of each landmark was recorded, from the sagittal, coronal, and axial views respectively. Then the values were exported into a spreadsheet (Microsoft Excel, Microsoft Corporation, Redmond, WA, USA) for analysis later. Each observer repeated the superimposing measurement 3 times at intervals of 5 days, yielding 90 sets by each observer. Statistical analyses in a statistical software package (SPSS version 21.0; SPSS, Chicago. IL, USA) were done. The first was to calculate the difference in the value of the coordinates (i.e. changes arising from treatment and growth) for all landmarks that was done by subtracting the pre- and post-treatment coordinate values of that landmark. The second was to estimatehe intraobserver agreement by computing the Intraclass correlation coefficients (ICCs). The distribution and variance of the data were evaluated using the Shapiro-Wilk normality test and Levene’s homogeneity test. T-test and Mann-Whitney U-test were used for inter-observer comparisons, and paired t-test was used for intraobserver reliability assessments. Results Voxel-based superimposition visually demonstrated, the morphological skeletal changes of the craniomaxillary region for these Class III patients after protraction therapy: The intraobserver agreement, as was estimated by the ICCs for the coordinate difference of each landmark, was listed in Table 2 . Generally, the results indicated excellent reliability for intraobserver assessments, with ICC > 0.90 for 25 (92.6%) of intraobserver assessments. Regarding the ICCs for the coordinate difference ,low ICC scores were obtained for 2 bilateral landmarks indicating a relatively low reliability.They were the X coordinate of the right and left zygomatic suture, and the Z coordinate of the right and left pyriform aperture. Table 3 showed the frequency counts of the difference in mean values of the coordinate (i.e. difference arising from treatment and growth for each landmark). This was used to assess the reproducibility of this measurement method. The precision of the measurement was better than 0.3 mm in 21 cases (77.8%). For the difference in mean values for the X, Y, and Z coordinates used to estimate interobserver reproducibility, similar ICC results were obtained.The interobserver reproducibility errors were < 0.3 mm in 21 of the 27 cases; only 6 cases (22.2%) showed error ≥ 0.3mm. Discussion Melsen 15 confirmed that by the age of 7, the growth of sphenoethmoidal and sphenofrontal suture of the anterior cranial base usually stops. The authors also pointed out that after 5 years of age, changes in sella turcica were most likely, to some degree, due to resorptive activity in the lower half of the posterior wall and the floor of the sella turcica. On the other hand, the anterior part of the sella turcica was the most stable, and resting (inactive) bone was observed in almost all subjects. The brain almost stops growing at 7–8 years of age, after which the anterior cranial base continues to grow and contributes to facial development. That growth occurs almost entirely due to increased pneumatization of the frontal and ethmoid bones 20 . This present study used the voxel based superimposition of CBCT data of the anterior cranial base in growing patients, to examine the coordinate difference in position between the pre- and post- treatment for skeletal class III malocclusion. Our patients’ age was 8–11, and hence choice of stable reference was approriate. The 3D analysis was conducted in 5 steps: model construction, model reorientation, voxel-based superimposition, landmark definition, and quantitative measurement. The coordinate system were automatically created by the software while the models were constructed. Although the coordinates of various structures on the reconstructed models might differ, that difference could usually be resolved by reorienting the models, that is, the coordinates of the pre- and post- treatment landmarks were very little affected. The superimposition methods were fully automated, with voxel-wise rigid registration of the anterior cranial base structures that have completed growth and did not change further with age 21 – 23 . The bilateral structural landmarks were involved for this study.: the nasion (N), the anterior nasal spine (ANS), A point (A), the right upper incisal alveolar ridge (rUIAR), the left upper incisal alveolar ridge (lUIAR), the right pyriform aperture (rPA), the left pyriform aperture (lPA), the right zygomatic suture (rZS), and the left zygomatic suture (lZS). The N, rPA, lPA, rZS, and lZS together reflected the changes in the upper part of the maxilloface. The ANS, A, rUIAR, and lUIAR together reflected the changes in the lower part of the maxilloface. In additional, the rUIAR and lUIAR reflected the changes in the premaxilla alveolar. Arising from the data handing process of this research, errors might occur during the following 4 steps: a) model reorientation, b) the voxel-based superimposition, c)localization(identification) of landmarks. First, even if the head for CBCT scans were consistently positioned according to the protocol, scan data with slight variations in head position would still occur due to such factors as varying body positions and neck curvatures. This might lead to inter-observer difference for cranial base registration.In this research, proper automated voxel registration need these two CBCT scanings approximated as far as possible, Two CBCTS with significant differences cannot be performed voxel registrationand. And different operators, using the same patient scans, the same references for registration, same software may or may not achieve proper registration. However, as the subjects’ craniofacial characteristics were basically symmetrical, the method error could be minimized by model reorientation. Second, the voxel-based superimposition was semi-automated—the observers selected the area and then the computer automatically superimposed.The error in the voxel-based superimposition depended on the area selected by the observers 24 . If in the first superimposition the region selected on the pre- and post- treatment model was not exactly the same, error would creep into the superimposition results. To overcome this, we continued the selection until the superimposition results were consistent. Third, there were 2 sources of error during landmark identification in this study: a) While it was relatively easy to identify the landmarks in the 3D virtual surface models, it could be difficult to select the best slice or region to localize the selected landmarks 25 ; b) The 3 spatial planes are interrelated. Adjusting the slice in one plane will result in movement of the reference line in another plane. Therefore, some experience on the part of the observers was essential, for which training using, 30 extra sets of scans was done beforehand for the observers. In the present study, although the 3 observers had different working backgrounds, that seemed to have little impact on the amount of errors in measurement. Training and calibration of the observers or assessors cannot be overemphasized in any studies. Other factors related to the precision and reproducibility of the 3D measurements would need to be further investigated, such as the voxel size, scanning time, and scanning range 26 . In this study, the voxel size used was 0.3 mm, whereas some other CBCT studies used a voxel size of 0.5 mm and up to 3 mm. Recent studies 27 , 28 indicated that the smaller the voxels, the better the measurement accuracy, and the smaller the measurement error. Inspite of the general reliability of the coordinate difference shown at Table 2 a for the right and left zygomatic suture, overall the results gained better intraobserver reliability and inter-observer reproducibility of this method. The less-than-perfect reproducibility maybe due to the ambiguous definition criteria, including choosiing inconsistently the best perspective and slice. In addition, Table 2 b showed that the reliability of the Z coordinate definition was inferior to the reliability of the X, Y coordinates definition, which can be related to that some landmarks are poorly recognizable in the Z coordinate. Therefore, reproducibility of the landmark is related to its characteristics. The choice of landmarks has an impact on the reliability and reproducibility of measurements 29 . In this study, we proposed a new 3D quantitative measurement method for the assessment of maxillary protraction treatment in skeletal Class III malocclusion. An orthodontist could spend about 5 minutes to overlap the pre- and post- treatment CBCT images, to demonstrate visually the therapeutic effect to patients and their parents 30 . Orthodontists could intuitively explain to patients the location and extent of treatment changes, for better patient's recognition and satisfaction. The landmarks selected for the study largely represented changes in the maxillofacial changes. Table 3 showed the ICCs was > 0.90 for 25 (92.6%) of the intraobserver assessments. The precision of the measurement method was < 0.3 mm in 21(77.8%) cases. Table 3 showed the interobserver reproducibility errors were < 0.3 mm in 21 of the 27 cases. Overall, the reliability and reproducibility of the method were excellent. Other new landmarks need to be proposed and tested to determine whether this method can be used for other growth or treatment assessment. Conclusion Overall, an excellent intraobserver reliability and interobserver reproducibility for the assessment of craniomaxillary changes is possible using voxel-based superimposition of CBCT models when measurement of the anterior cranial base of growing patients with skeletal class III malocclusion patients is concerened. And it was also convenient and intuitively to explain the therapeutic process and improvement in craniomaxillary positions to the patient after maxillary protraction . Declarations Ethics approval and consent to participate All experiments were performed in accordance with relevant guidelines and regulations (Declarations of Helsinki). Study protocol was approved by the Medical Ethical Commission of the University of Hong Kong-Shenzhen Hospital. The informed consents from all subjects and/or their legal guardian(s) have been obtained for study participation. Consent for publication The informed consents from all subjects and/or their legal guardian(s) have been obtained for publication of identifying information/images in an online open-access publication. A vailability of data and materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no Competing interest. Funding: This work was supported by grants from the Program of Key Science and Technology Research, Health Commission of Hebei Province (Project No. 20191074). Clinical trial number: Not applicable. Authors' contributions XiaoYing Hu 1* made substantial contributions to design of the work,and the acquisition, analysis and interpretation of data, and revise the manuscript. Gary Shun Pan Cheung 2 contributed to the conception and analysis of data, and revise the manuscript. YiYang Zhang 3 involved in the interpretingand drafting the manuscript. RuoNan Sun 4 drafted and performed the work and drafted the manuscript. FuSheng Dong 5 have made substantial contributions to the conception, design of the experimental work and analysis of data. Acknowledgements None Authors' information (optional) XiaoYing Hu 1 * ,orthodontist. There are about 6000 outpatient visits per year. She have finished the correction of over 1000 cases with Class III Malocclusion.During the management of these patients,she noted the deleterious effect of bad tongue habit on the development of Class III Malocclusion.The bad tongue habit alsocaused narrowing of the upper airway even in deciduous period of about 1-2years of age. So she consulted two experts to investigate the topics. The data show the craniofacial and upper airway characteristics with Class III malocclusion in 4 to5year-old children, and reflect the outcome of the early intervention quatitatively She also wish obtained to find a way to decrease the recurrence of Class III malocclusion. Two experts ： Gary Shun Pan Cheung . 2 :formerly of the Faculty of Dentistry, The University of Hong Kong, Hong Kong. E-mail: [email protected] FuSheng Dong 5 : Key Laboratory, College of Stomatology, Hebei Medical University, Hebei 50017, China. E-mail: [email protected] References Ngan P, Yiu C, Hu A, Hägg U, Wei SH. Cephalometric and occlusal changes following maxillary expansion and protraction. Eur J Orthod. 1998;20(3):237–54. 10.1093/ejo/20.3.237 . Baldini B, Cavagnetto D, Baselli G, Sforza C, Tartaglia GM. Cephalometric measurements performed on CBCT and reconstructed lateral cephalograms: a cross-sectional study providing a quantitative approach of differences and bias. BMC Oral Health. 2022;22(1):98. 10.1186/s12903-022-02131-3 . PMID: 35351080; PMCID: PMC8966183. Iyer SR, Premkumar S, Muruganandam M. 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Intarasuksanti C, Prapayasatok S, Kampan N, Sirabanchongkran S, Mahakkanukrauh P, Sastraruji T, Khongkhunthian P, Kuharattanachai K, Tripuwabhrut K. Effects of the cone-beam computed tomography protocol on the accuracy and image quality of root surface area measurements: An in vitro study. Imaging Sci Dent. 2023;53(4):325–33. Epub 2023 Sep 25. PMID: 38174039; PMCID: PMC10761297. Yu S, Zheng Y, Dong L, Huang W, Wu H, Zhang Q, Yan X, Wu W, Lv T, Yuan X. The accuracy and reliability of different midsagittal planes in the symmetry assessment using cone-beam computed tomography. Clin Anat. 2024;37(2):218–26. Epub 2024 Jan 8. PMID: 38186377. Koerich L, Tufekci E, Lindauer SJ. 3D Imaging to assess growth and treatment effects. Craniofac 3D Imaging 2019,51–69. Tables Table 1. Landmarks selected for the study. Landmark name Anatomic region Lateral view Axial view Anteroposterior view 1.Nasion (N) Frontonasal suture Anterior-most point Middle-anterior–most point on the anterior contour Middle point 2.Anterior nasal spine (ANS) Median, sharp bony process of the maxilla Point on the tip Anterior-most point Middle point in the anteroposterior slice determined by the lateral and axial view 3. A point (A) Premaxilla Posterior-most point on the curve of the maxilla between the anterior nasal spine and supradentale Middle-anterior–most point on the tip of the premaxilla Middle point in the anteroposterior slice determined by the lateral and axial views 4. Right upper incisal alveolar ridge(rUIAR) Premaxilla alveolar Anterior-inferior–most point Anterior-most point Middle point in the anteroposterior slice determined by the lateral and axial view 5.Left upper incisal alveolar ridge(lUIAR) Premaxilla alveolar Anterior-inferior–most point Anterior-most point Middle point in the anteroposterior slice determined by the lateral and axial view 6.Right pyriform aperture(rPA) pyriform aperture Anterior-most point in the Lateral slice determined by the Anteroposterior view and axial view Anterior-most point Lateral–most poin 7.Left pyriform aperture(lPA) pyriform aperture Anterior-most point in the Lateral slice determined by the Anteroposterior view and axial view Anterior-most point Lateral–most poin 8.Right Zygomatic suture (rZS) Zygomaticomaxillary suture Anterior-inferior–most point Anterior-most point Lateral-inferior–most point 9.Left Zygomatic suture (lZS) Zygomaticomaxillary suture Anterior-inferior–most point Anterior-most point Lateral-inferior–most point Table 2a. Assessment of intraobserver reliability: (a)Intraclass correlation Coefficient(ICC) and confidence interval for repeated measurements (from the triplicate evaluation). Landmark Intraclass Correlation 95% Confidence Interval X Y Z X Y Z Nasion (N) 0.96 0.99 0.97 0.89-0.99 0.94-1.00 0.91-1.00 Anterior nasal spine (ANS) 0.96 0.98 0.98 0.90-0.99 0.92-1.00 0.92-1.00 A point (A) 0.97 0.92 0.99 0.92-0.99 0.81-0.96 0.95-1.00 Right upper incisal alveolar ridge(rUIAR) 0.95 0.98 0.97 0.86-0.98 0.90-1.00 0.90-1.00 Left upper incisal alveolar ridge(lUIAR) 0.94 0.98 0.98 0.85-0.98 0.92-1.00 0.92-1.00 Right pyriform aperture(rPA) 0.95 0.97 0.78 0.85-0.99 0.90-0.99 0.62-0.84 Left pyriform aperture(lPA) 0.96 0.97 0.81 0.89-0.99 0.91-1.00 0.74-0.89 Right Zygomatic suture (rZS) 0.91 0.96 0.94 0.80-0.95 0.89-0.99 0.85-0.98 Left Zygomatic suture (lZS) 0.90 0.95 0.94 0.80-0.94 0.86-0.99 0.83-0.98 Table 2b. Assessment of intraobserver reliability: (b)ICC values of changes in madibular measurements difference in X, Y, and Z coordinates. Range Coordinate difference X Y Z Total n (%) n (%) n (%) n (%) ICC≥0.95 6 （66.7） 8 （88.9） 5 （55.6） 19 （70.4） 0.90≤ICC＜0.95 3 （33.3） 1 （11.1） 2 （22.2） 6 （22.2） 0.85≤ICC＜0.90 0 0 0 0 0 0 0 0 0.80≤ICC＜0.85 0 0 0 0 1 （11.1） 1 （3.7） ICC＜0.80 0 0 0 0 1 （11.1） 1 （3.7） Total 9 (100.0) 9 (100.0) 9 (100.0) 27 (100.0) Table 3 Frequency of the difference in mean values for difference among measurement (mm) and for reproducibility of the measurement method (mm) Among measurement Reproducibility of the measurement method Range (mm) Coordinate difference Coordinate difference X Y Z Total X Y Z Total n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) ≥0.3 2 -22.2 1 -11.1 3 -33.3 6 -22.2 2 -22.2 1 -11.1 3 -33.3 6 -22.2 0.15≤x＜0.3 7 -77.8 7 -77.7 6 -66.7 20 -74.1 7 -77.8 7 -77.7 6 -66.7 20 -74.1 ≤0.15 0 0 1 -11.1 0 0 1 -3.7 0 0 1 -11.1 0 0 1 -3.7 Total 9 -100 9 -100 9 -100 27 -100 9 -100 9 -100 9 -100 27 -100 Additional Declarations No competing interests reported. Supplementary Files file.xls Cite Share Download PDF Status: Published Journal Publication published 09 Oct, 2025 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 21 Aug, 2024 Editor assigned by journal 20 Aug, 2024 Submission checks completed at journal 19 Aug, 2024 First submitted to journal 10 Aug, 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4890919","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":342972999,"identity":"71cb64e2-e759-49e1-8ce6-fb402589b2b7","order_by":0,"name":"XiaoYing Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYBACAxCRUHEATDMTr+XBGVK1MD5sI0WLuUSOmUTivDvGBgfYH38uYLDJl3cgoMVyRlqaROK2Z2YGB3gMjGcwpFluPEDIYTeSjwG1HLYxuP+GIZmH4bCBYQNBLYltEolzgFoOsD84TKQWkC0Nh4EOYzBsBmmRJ6CDweDMs2SLhGOHjSUP8Bgz8xikGRgQ1HI8x/Dmj5rDhn2gEOOpsDGQJ+QwIGCRQDIBiA4Q1sL8AYVLjC2jYBSMglEwsgAAB95BVaTUy7sAAAAASUVORK5CYII=","orcid":"","institution":"University of Hong Kong - Shenzhen Hospital","correspondingAuthor":true,"prefix":"","firstName":"XiaoYing","middleName":"","lastName":"Hu","suffix":""},{"id":342973000,"identity":"a16d81be-06d5-46a8-b561-4423f83f9e5d","order_by":1,"name":"Shun Pan Cheung Gary","email":"","orcid":"","institution":"University of Hong Kong - Shenzhen Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shun","middleName":"Pan Cheung","lastName":"Gary","suffix":""},{"id":342973001,"identity":"1c36dbbd-c087-446c-b868-8c1ce53b7329","order_by":2,"name":"YiYang Zhang","email":"","orcid":"","institution":"Hebei University","correspondingAuthor":false,"prefix":"","firstName":"YiYang","middleName":"","lastName":"Zhang","suffix":""},{"id":342973002,"identity":"6eb8be4a-669e-4c6b-859c-a36fdf1a857c","order_by":3,"name":"RuoNan Sun","email":"","orcid":"","institution":"Shijiazhuang City Second Hospital","correspondingAuthor":false,"prefix":"","firstName":"RuoNan","middleName":"","lastName":"Sun","suffix":""},{"id":342973004,"identity":"15281a22-6303-4c10-880a-c534cb5fbcfe","order_by":4,"name":"Fusheng Dong","email":"","orcid":"","institution":"Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fusheng","middleName":"","lastName":"Dong","suffix":""}],"badges":[],"createdAt":"2024-08-10 09:07:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4890919/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4890919/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-025-06049-x","type":"published","date":"2025-10-09T15:57:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66632084,"identity":"f58af529-edd2-4b5e-b460-5e7031ecc8f8","added_by":"auto","created_at":"2024-10-15 04:56:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":231560,"visible":true,"origin":"","legend":"\u003cp\u003eReorientation of the 3D model. In the lateral view, bilateral structures, such as the orbits, external auditory canals and other structures as much as possible overlap, and the Frankfort horizontal plane was oriented horizontally.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4890919/v1/3828832fd92cb32a2c412ebe.jpg"},{"id":66632025,"identity":"d4c22dcd-09f3-4a6b-bdf5-fa0cf51efb17","added_by":"auto","created_at":"2024-10-15 04:55:56","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":189589,"visible":true,"origin":"","legend":"\u003cp\u003eThe superimposition region selected in the CBCT volumes. Axial, sagittal, and coronal slice views of the volumes were used to select the anatomical structures of the anterior cranial base.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4890919/v1/6b4cace61729384663a80f3b.jpg"},{"id":66632027,"identity":"7c835974-7c9f-4b39-986c-761df1b114ea","added_by":"auto","created_at":"2024-10-15 04:56:00","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":449173,"visible":true,"origin":"","legend":"\u003cp\u003eLandmarks displayed in the 3D virtual surface model.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4890919/v1/bb46e0a1267cf544dbf2c0e9.jpg"},{"id":66632026,"identity":"8cd8d350-3293-4508-a3bf-b641b9cf6510","added_by":"auto","created_at":"2024-10-15 04:55:59","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":343901,"visible":true,"origin":"","legend":"\u003cp\u003eExample of identification of the ANS point in the 3 planes of space. The software allows tracking of the cursor with display of all 3 planes of space and 3D rendering in the same software window to verify landmark location.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4890919/v1/b2780e0cc36ebf7304c97a3c.jpg"},{"id":93419741,"identity":"66caafae-eddf-4e92-b6de-7e89af6dfdd6","added_by":"auto","created_at":"2025-10-13 16:06:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1982028,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4890919/v1/ebc88d1f-7f5d-4fdc-8f22-d9036aa9be32.pdf"},{"id":66632083,"identity":"81e20e0c-817c-412e-bd42-d858db5ae6f0","added_by":"auto","created_at":"2024-10-15 04:56:14","extension":"xls","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":388608,"visible":true,"origin":"","legend":"","description":"","filename":"file.xls","url":"https://assets-eu.researchsquare.com/files/rs-4890919/v1/dcdb9d3f3987ff0ed1d8af89.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reliability and Reproducibility of CBCT Assessment of craniomaxillary Changes Before and After Treatment for Class III Growing Patients – An convenient and intuitively Way for Evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSkeletal Class III malocclusions are the abnormal relationship between maxilla and mandible due to uneven growth of the two bony structures. About 42\u0026ndash;63% of patients belong to the maxillary hypoplasia with the mandible being of normal size or slight prognathic type\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Maxillary protraction is recommended for such skeletal Class III patients with maxillary deficiency.\u003c/p\u003e \u003cp\u003eTraditionally the cephalograms pre-and post- treatment were compared by superimposing stable structures such as the anterior cranial base, to evaluate the effect of maxillary protraction and maxillofacial changes\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. However, the simple sagittal assessments using 2-dimensional (2D) lateral cephalogram are prone to errors where accurate determination of some landmarks is concerned, because of failure to the anatomic structures\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e there. Also,as patients with skeletal malocclusion often are associated with facial asymmetry\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, 2D assessment cannot be accurate or reliable. With the advent of imaging technology, cone-beam computed tomography (CBCT) has been preferred as the method of choice for maxillofacial imaging,and as a valuable tool for orthodontic treatment planning and clinical research. CBCT would provide a comprehensive analysis of any three-dimensional (3D) changes in the size, shape and position of the maxillofacial structures\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e .In particular, it affords a more accurate assessment of the labiopalatal direction and the contact relationship between adjacent teeth ,when compared to 2D radiography\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Superimposition of virtual models is necessary for 3D measurements, a process that is much more complex than with 2D images. Identification of landmarks the first step, which is also prone to errors. Despite the difficulty, some researchers have made progress and achieved good reliability\u003csup\u003e\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. For instance, Lagrav\u0026egrave;re and coworkers\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e put forward an ELSA standardized coordinate system based on 4 landmarks: (i) midpoint between the geometric centers of the foramina spinosum; (ii \u0026amp; iii) the right (rSLEAM) and left superior-lateral border of the external auditory meatus (lSLEAM); and (iv) the mid-dorsum foramen magnum (MDFM). However, because the skull base is situated far away from the face, any discrepancy are amplified when the craniomaxillary features were mapped to the coordinate system. Later, the error is the 3D superposition measurements will be coamplified,which can become clinically significant.\u003c/p\u003e \u003cp\u003eStudying the growth of the craniomaxillary structure relies on measurements made to stable locations in the skul\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003el\u003c/span\u003e, such as that anterior cranial base\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. The cribriform ethmoid plate growth ceased by the age of 2.That is, the pubertal growth spur has much less pronounced effect on the anterior cranial base\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. With different methodologies (longitudinal cephalometry\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, histology\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003eand dry-skull measurements\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e), three groups of researchers reported that the sphenoethmoid synchondrosis growth stand-by age 7. Therefore, the pre-sphenoid region (the plane surface on the sphenoid bone, in front of sella turcica) ,which is considered stable after 7 years of age\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, were noted as stable in craniomaxillary region of growing individuals. They may then be used as stable reference, as well as treatment changes.\u003c/p\u003e \u003cp\u003eVoxel-based registration of changes with 3D CBCT images has been used in the past few years to evaluate overall facial changes relative to the cranial base\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. But then, regional craniomaxillary registrations were still controversial. This present study, aimed to evaluate the 3-dimensional craniomaxillary changes in growing patients, who had received orthodontic treatment for Class III malocclusion, and to examine the intraobserver reliability and inter-observer reproducibility of a voxel-based superimposition method.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eCorresponding pairs of pre- and post-treatment CBCT scans of 27 children, aged 8\u0026ndash;11 years before treatment, who had received protraction therapy for their Class III malocclusion at the Department of Orthodontics of the University of Hong Kong-Shenzhen Hospital were included in this study. All patients or their parents gave consent to participate in this study, after hearing a thorough explanation of the research objectives and procedures. The two scans were taken on average 24 to 26 months apart. The scan was included in the analysis based on : cervical vertebral maturation (CS1-CS3); clear and legible 3D images; Class III malocclusion The Exclusion criteria were: discernible craniofacial asymmetry; discernible mandibular asymmetry; temporomandibular joint disorders; history of maxillofacial trauma or surgery in the region; some systemic disease; and previous orthodontic treatment. The study protocol was approved by the Medical Ethics Commission of the University of Hong Kong-Shenzhen Hospital.\u003c/p\u003e \u003cp\u003eThe parameters of the CBCT machine (Dental Volumetric Tomograph, KaVo 3D eXam, Imaging Sciences International LLC, Hatfield, PA, USA) were set at 120 kVp, 18.54mA, 23 x 17 cm field of view, 0.3 mm voxel size, and scan time of 8.9 s. Data were exported in DICOM format into a 3D imaging software (InvivoDental software 5.1.3, Anatomage Inc, San Jose, USA), in which a virtual model of the patient was created in a 3D coordinate system. The position and orientation of the 3D model in the coordinate system depended on the head position of the patient when the CBCT scanned. In the \"section\" module, using axial, coronal, and sagittal views on the left side, the 3D virtual model on the right side was oriented: in the lateral view, bilateral structures, such as the orbits, external auditory canals and other structures as much as possible overlap, and the Frank-fort horizontal plane was oriented horizontally\u003csup\u003eFigure \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe software offered a \u0026ldquo;superimposition\u0026rdquo; module to achieve fully automated voxel-based superimposition of the pre- and post-treatment scan, some stable anatomical area had to be defined first. This was done by clicking on the \"voxel registration\" button, which called up 3 boxes in the sagittal, coronal and axial view for the observer to select the stable region to guide the superimposition. The boxes were used to select the anatomical structures\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e of the anterior cranial base in the 3D models \u003csup\u003eFigure \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. After clicking on the \"start\" button and the automatic voxel-based superimposition of the 3D images began. Stable reference structure that guided the superimposition.The whole process of registration and superimposition took approximately 3 minutes.\u003c/p\u003e \u003cp\u003eA total of 9 landmarks (or 6 in total, if the left and right were considered as contributing to one landmark) and defined criteria were established for each landmark. A total of 9 landmarks were located by each observer independently on every surface-rendered 3D model \u003csup\u003eTable\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e and Figure\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. To identify the landmarks, the observer would navigate to any (sagittal, coronal or axial) view and select the most appropriate slice in that view for registration. The three-dimensional coordinates of each landmark were then automatically recorded by the software. For those landmarks that might be difficult to define in a special view, the observer could call up the surface-rendered model to assist with the localization \u003csup\u003eFigure \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThree observers (an orthodontist, an orthodontics master, and a dental radiologist) were trained and calibrated to complete the entire superimposing measurement process using a set of 30 CBCT scans not included in this study. Then, the 3 observers worked independently throughout, to define the 9 anatomical landmarks\u003csup\u003eTable\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e in the superimposed CBCT volume (from pre- and post treatment for the same patient), as described above.The X, Y and Z coordinate of each landmark was recorded, from the sagittal, coronal, and axial views respectively. Then the values were exported into a spreadsheet (Microsoft Excel, Microsoft Corporation, Redmond, WA, USA) for analysis later. Each observer repeated the superimposing measurement 3 times at intervals of 5 days, yielding 90 sets by each observer.\u003c/p\u003e \u003cp\u003eStatistical analyses in a statistical software package (SPSS version 21.0; SPSS, Chicago. IL, USA) were done. The first was to calculate the difference in the value of the coordinates (i.e. changes arising from treatment and growth) for all landmarks that was done by subtracting the pre- and post-treatment coordinate values of that landmark. The second was to estimatehe intraobserver agreement by computing the Intraclass correlation coefficients (ICCs). The distribution and variance of the data were evaluated using the Shapiro-Wilk normality test and Levene\u0026rsquo;s homogeneity test. T-test and Mann-Whitney U-test were used for inter-observer comparisons, and paired t-test was used for intraobserver reliability assessments.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eVoxel-based superimposition visually demonstrated, the morphological skeletal changes of the craniomaxillary region for these Class III patients after protraction therapy:\u003c/p\u003e\n\u003cp\u003eThe intraobserver agreement, as was estimated by the ICCs for the coordinate difference of each landmark, was listed in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Generally, the results indicated excellent reliability for intraobserver assessments, with ICC\u0026thinsp;\u0026gt;\u0026thinsp;0.90 for 25 (92.6%) of intraobserver assessments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the ICCs for the coordinate difference ,low ICC scores were obtained for 2 bilateral landmarks indicating a relatively low reliability.They were the X coordinate of the right and left zygomatic suture, and the Z coordinate of the right and left pyriform aperture.\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e showed the frequency counts of the difference in mean values of the coordinate (i.e. difference arising from treatment and growth for each landmark). This was used to assess the reproducibility of this measurement method. The precision of the measurement was better than 0.3 mm in 21 cases (77.8%). For the difference in mean values for the X, Y, and Z coordinates used to estimate interobserver reproducibility, similar ICC results were obtained.The interobserver reproducibility errors were \u0026lt;\u0026thinsp;0.3 mm in 21 of the 27 cases; only 6 cases (22.2%) showed error\u0026thinsp;\u0026ge;\u0026thinsp;0.3mm.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMelsen\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e confirmed that by the age of 7, the growth of sphenoethmoidal and sphenofrontal suture of the anterior cranial base usually stops. The authors also pointed out that after 5 years of age, changes in sella turcica were most likely, to some degree, due to resorptive activity in the lower half of the posterior wall and the floor of the sella turcica. On the other hand, the anterior part of the sella turcica was the most stable, and resting (inactive) bone was observed in almost all subjects. The brain almost stops growing at 7\u0026ndash;8 years of age, after which the anterior cranial base continues to grow and contributes to facial development. That growth occurs almost entirely due to increased pneumatization of the frontal and ethmoid bones\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. This present study used the voxel based superimposition of CBCT data of the anterior cranial base in growing patients, to examine the coordinate difference in position between the pre- and post- treatment for skeletal class III malocclusion. Our patients\u0026rsquo; age was 8\u0026ndash;11, and hence choice of stable reference was approriate. The 3D analysis was conducted in 5 steps: model construction, model reorientation, voxel-based superimposition, landmark definition, and quantitative measurement. The coordinate system were automatically created by the software while the models were constructed. Although the coordinates of various structures on the reconstructed models might differ, that difference could usually be resolved by reorienting the models, that is, the coordinates of the pre- and post- treatment landmarks were very little affected. The superimposition methods were fully automated, with voxel-wise rigid registration of the anterior cranial base structures that have completed growth and did not change further with age\u003csup\u003e\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The bilateral structural landmarks were involved for this study.: the nasion (N), the anterior nasal spine (ANS), A point (A), the right upper incisal alveolar ridge (rUIAR), the left upper incisal alveolar ridge (lUIAR), the right pyriform aperture (rPA), the left pyriform aperture (lPA), the right zygomatic suture (rZS), and the left zygomatic suture (lZS). The N, rPA, lPA, rZS, and lZS together reflected the changes in the upper part of the maxilloface. The ANS, A, rUIAR, and lUIAR together reflected the changes in the lower part of the maxilloface. In additional, the rUIAR and lUIAR reflected the changes in the premaxilla alveolar.\u003c/p\u003e \u003cp\u003eArising from the data handing process of this research, errors might occur during the following 4 steps: a) model reorientation, b) the voxel-based superimposition, c)localization(identification) of landmarks. First, even if the head for CBCT scans were consistently positioned according to the protocol, scan data with slight variations in head position would still occur due to such factors as varying body positions and neck curvatures. This might lead to inter-observer difference for cranial base registration.In this research, proper automated voxel registration need these two CBCT scanings approximated as far as possible, Two CBCTS with significant differences cannot be performed voxel registrationand. And different operators, using the same patient scans, the same references for registration, same software may or may not achieve proper registration. However, as the subjects\u0026rsquo; craniofacial characteristics were basically symmetrical, the method error could be minimized by model reorientation. Second, the voxel-based superimposition was semi-automated\u0026mdash;the observers selected the area and then the computer automatically superimposed.The error in the voxel-based superimposition depended on the area selected by the observers\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. If in the first superimposition the region selected on the pre- and post- treatment model was not exactly the same, error would creep into the superimposition results. To overcome this, we continued the selection until the superimposition results were consistent. Third, there were 2 sources of error during landmark identification in this study: a) While it was relatively easy to identify the landmarks in the 3D virtual surface models, it could be difficult to select the best slice or region to localize the selected landmarks\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e; b) The 3 spatial planes are interrelated. Adjusting the slice in one plane will result in movement of the reference line in another plane. Therefore, some experience on the part of the observers was essential, for which training using, 30 extra sets of scans was done beforehand for the observers. In the present study, although the 3 observers had different working backgrounds, that seemed to have little impact on the amount of errors in measurement. Training and calibration of the observers or assessors cannot be overemphasized in any studies. Other factors related to the precision and reproducibility of the 3D measurements would need to be further investigated, such as the voxel size, scanning time, and scanning range\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. In this study, the voxel size used was 0.3 mm, whereas some other CBCT studies used a voxel size of 0.5 mm and up to 3 mm. Recent studies\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e indicated that the smaller the voxels, the better the measurement accuracy, and the smaller the measurement error.\u003c/p\u003e \u003cp\u003eInspite of the general reliability of the coordinate difference shown at Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003ea for the right and left zygomatic suture, overall the results gained better intraobserver reliability and inter-observer reproducibility of this method. The less-than-perfect reproducibility maybe due to the ambiguous definition criteria, including choosiing inconsistently the best perspective and slice. In addition, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003eb showed that the reliability of the Z coordinate definition was inferior to the reliability of the X, Y coordinates definition, which can be related to that some landmarks are poorly recognizable in the Z coordinate. Therefore, reproducibility of the landmark is related to its characteristics. The choice of landmarks has an impact on the reliability and reproducibility of measurements\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, we proposed a new 3D quantitative measurement method for the assessment of maxillary protraction treatment in skeletal Class III malocclusion. An orthodontist could spend about 5 minutes to overlap the pre- and post- treatment CBCT images, to demonstrate visually the therapeutic effect to patients and their parents\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Orthodontists could intuitively explain to patients the location and extent of treatment changes, for better patient's recognition and satisfaction. The landmarks selected for the study largely represented changes in the maxillofacial changes. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e showed the ICCs was \u0026gt;\u0026thinsp;0.90 for 25 (92.6%) of the intraobserver assessments. The precision of the measurement method was \u0026lt;\u0026thinsp;0.3 mm in 21(77.8%) cases. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e showed the interobserver reproducibility errors were \u0026lt;\u0026thinsp;0.3 mm in 21 of the 27 cases. Overall, the reliability and reproducibility of the method were excellent. Other new landmarks need to be proposed and tested to determine whether this method can be used for other growth or treatment assessment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, an excellent intraobserver reliability and interobserver reproducibility for the assessment of craniomaxillary changes is possible using voxel-based superimposition of CBCT models when measurement of the anterior cranial base of growing patients with skeletal class III malocclusion patients is concerened. And it was also convenient and intuitively to explain the therapeutic process and improvement in craniomaxillary positions to the patient after maxillary protraction .\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll experiments were performed in accordance with relevant guidelines and regulations (Declarations of\u0026nbsp;Helsinki).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudy protocol was approved by the Medical Ethical Commission of the University of Hong Kong-Shenzhen Hospital.\u003c/p\u003e\n\u003cp\u003eThe informed consents from all subjects and/or their legal guardian(s) have been obtained for study participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe informed consents from all subjects and/or their legal guardian(s) have been obtained \u0026nbsp;for publication of identifying information/images in an online open-access publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003evailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no Competing interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the Program of Key\u0026nbsp;Science and\u0026nbsp;Technology\u0026nbsp;Research,\u0026nbsp;Health Commission of Hebei Province (Project No. 20191074).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eXiaoYing Hu \u003csup\u003e1*\u003c/sup\u003e\u003c/em\u003emade substantial contributions to design of the work,and the acquisition, analysis\u0026nbsp;and\u0026nbsp;interpretation of data, and revise the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGary\u003c/em\u003e\u003cem\u003eShun\u003c/em\u003e\u003cem\u003ePan\u003c/em\u003e\u003cem\u003eCheung\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e contributed\u0026nbsp;to the conception and analysis of data, and revise the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYiYang Zhang\u003csup\u003e3\u003c/sup\u003e\u003c/em\u003e involved in the interpretingand drafting\u0026nbsp;the \u0026nbsp;manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRuoNan Sun \u003csup\u003e4\u003c/sup\u003e\u003c/em\u003e drafted\u0026nbsp;and performed\u0026nbsp;the work\u0026nbsp;and\u0026nbsp;drafted\u0026nbsp;\u0026nbsp;the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFuSheng Dong \u003csup\u003e5\u003c/sup\u003e\u003c/em\u003e have made substantial contributions to the conception, design of the\u0026nbsp;experimental\u0026nbsp;work and analysis of data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eXiaoYing Hu\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u003csup\u003e\u0026nbsp;1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/em\u003e,orthodontist. There are about 6000 outpatient visits per year. She have finished the correction\u0026nbsp;of\u0026nbsp;over 1000 cases with Class III Malocclusion.During the\u0026nbsp;management of these patients,she\u0026nbsp;noted the deleterious\u0026nbsp;effect of bad tongue habit on the development of Class III Malocclusion.The bad tongue habit\u0026nbsp;alsocaused\u0026nbsp;narrowing of the\u0026nbsp;upper\u0026nbsp;airway\u0026nbsp;even\u0026nbsp;in deciduous period\u0026nbsp;of\u0026nbsp;about 1-2years\u0026nbsp;of age. So she consulted \u003cstrong\u003etwo experts\u003c/strong\u003e to investigate the topics. The data show the craniofacial and upper airway characteristics with Class III malocclusion in 4 to5year-old children, and reflect the outcome of the early intervention quatitatively She also wish obtained \u0026nbsp;to find a way to decrease the recurrence of Class III malocclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTwo experts\u003c/strong\u003e：\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cem\u003eGary\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eShun\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003ePan\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;Cheung\u003c/em\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e:formerly of the Faculty of Dentistry, The University of Hong Kong, Hong Kong. E-mail:[email protected]\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eFuSheng Dong \u003csup\u003e5\u003c/sup\u003e\u003c/em\u003e: Key Laboratory, College of Stomatology, Hebei Medical University, Hebei\u0026nbsp;50017,\u0026nbsp;China.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eE-mail: [email protected]\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNgan P, Yiu C, Hu A, H\u0026auml;gg U, Wei SH. Cephalometric and occlusal changes following maxillary expansion and protraction. Eur J Orthod. 1998;20(3):237\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ejo/20.3.237\u003c/span\u003e\u003cspan address=\"10.1093/ejo/20.3.237\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaldini B, Cavagnetto D, Baselli G, Sforza C, Tartaglia GM. 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PMID: 38174039; PMCID: PMC10761297.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu S, Zheng Y, Dong L, Huang W, Wu H, Zhang Q, Yan X, Wu W, Lv T, Yuan X. The accuracy and reliability of different midsagittal planes in the symmetry assessment using cone-beam computed tomography. Clin Anat. 2024;37(2):218\u0026ndash;26. Epub 2024 Jan 8. PMID: 38186377.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoerich L, Tufekci E, Lindauer SJ. 3D Imaging to assess growth and treatment effects. Craniofac 3D Imaging 2019,51\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Landmarks selected for the study.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLandmark name\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAnatomic region\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLateral view\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAxial view\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAnteroposterior view\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e1.Nasion (N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003eFrontonasal suture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle-anterior\u0026ndash;most point on the anterior contour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle point\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e2.Anterior nasal spine (ANS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003eMedian, sharp bony process of the maxilla\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003ePoint on the tip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle point in the anteroposterior slice determined by the lateral and axial view\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e3. A point (A)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003ePremaxilla\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003ePosterior-most point on the curve of the maxilla between the anterior nasal spine and supradentale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle-anterior\u0026ndash;most point on the tip of the premaxilla\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle point in the anteroposterior slice determined by the lateral and axial views\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e4. Right upper incisal alveolar ridge(rUIAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003ePremaxilla alveolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-inferior\u0026ndash;most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle point in the anteroposterior slice determined by the lateral and axial view\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e5.Left upper incisal alveolar ridge(lUIAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003ePremaxilla alveolar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-inferior\u0026ndash;most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle point in the anteroposterior slice determined by the lateral and axial view\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e6.Right pyriform aperture(rPA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003epyriform aperture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point in the Lateral slice determined by the Anteroposterior view and axial view\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eLateral\u0026ndash;most poin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e7.Left pyriform aperture(lPA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003epyriform aperture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point in the Lateral slice determined by the Anteroposterior view and axial view\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eLateral\u0026ndash;most poin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e8.Right Zygomatic suture (rZS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003eZygomaticomaxillary suture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-inferior\u0026ndash;most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eLateral-inferior\u0026ndash;most point\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.43661971830986%\" valign=\"top\"\u003e\n \u003cp\u003e9.Left Zygomatic suture (lZS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.133802816901408%\" valign=\"top\"\u003e\n \u003cp\u003eZygomaticomaxillary suture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.176056338028168%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-inferior\u0026ndash;most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior-most point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.535211267605632%\" valign=\"top\"\u003e\n \u003cp\u003eLateral-inferior\u0026ndash;most point\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2a. Assessment of intraobserver reliability: (a)Intraclass correlation Coefficient(ICC) and confidence interval for repeated measurements (from the triplicate evaluation).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.371278458844134%\" rowspan=\"2\" valign=\"bottom\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLandmark\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.64798598949212%\" colspan=\"3\" valign=\"top\" style=\"width: 43.167%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eIntraclass Correlation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.64798598949212%\" colspan=\"3\" valign=\"top\" style=\"width: 17.653%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e95% Confidence Interval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.571428571428573%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.571428571428573%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.857142857142858%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.571428571428573%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.571428571428573%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.857142857142858%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.371278458844134%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eNasion (N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.157618213660244%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.157618213660244%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.332749562171628%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.157618213660244%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.89-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.157618213660244%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.94-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.332749562171628%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.91-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eAnterior nasal spine (ANS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.90-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.92-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.92-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eA point (A)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.92-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.81-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.95-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eRight upper incisal alveolar ridge(rUIAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.86-0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.90-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.90-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eLeft upper incisal alveolar ridge(lUIAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.85-0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.92-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.92-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eRight pyriform aperture(rPA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.85-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.90-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.62-0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eLeft pyriform aperture(lPA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.89-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.91-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.74-0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eRight Zygomatic suture (rZS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.80-0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.89-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.85-0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.640625%\" valign=\"top\" style=\"width: 27.9965%;\"\u003e\n \u003cp\u003eLeft Zygomatic suture (lZS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 14.343%;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 14.4809%;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 7.3094%;\"\u003e\n \u003cp\u003e0.80-0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.328125%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.86-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.5234375%\" valign=\"top\" style=\"width: 5.2407%;\"\u003e\n \u003cp\u003e0.83-0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2b. Assessment of intraobserver reliability: (b)ICC values of changes in madibular measurements difference in X, Y, and Z coordinates.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.028846153846153%\" rowspan=\"3\" valign=\"bottom\" style=\"width: 12.8905%;\"\u003e\n \u003cp\u003e\u003cem\u003eRange\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.97115384615385%\" colspan=\"6\" style=\"width: 42.63%;\"\u003e\n \u003cp\u003e\u003cem\u003eCoordinate difference\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" colspan=\"2\" valign=\"bottom\" style=\"width: 12.992%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.07792207792208%\" colspan=\"2\" valign=\"bottom\" style=\"width: 14.7175%;\"\u003e\n \u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.07792207792208%\" colspan=\"2\" valign=\"bottom\" style=\"width: 14.7175%;\"\u003e\n \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.07792207792208%\" colspan=\"2\" valign=\"bottom\" style=\"width: 13.2965%;\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.376623376623378%\" colspan=\"2\" valign=\"top\" style=\"width: 12.992%;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.246376811594203%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.391304347826086%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.246376811594203%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.391304347826086%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.246376811594203%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.391304347826086%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.695652173913043%\" valign=\"top\" style=\"width: 3.857%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.391304347826086%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.072289156626507%\" valign=\"top\" style=\"width: 12.8905%;\"\u003e\n \u003cp\u003eICC\u0026ge;0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.819277108433735%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.566265060240964%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e（66.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.819277108433735%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.566265060240964%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e（88.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.819277108433735%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.566265060240964%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（55.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.783132530120482%\" valign=\"top\" style=\"width: 3.857%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.566265060240964%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（70.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.367521367521366%\" valign=\"top\" style=\"width: 12.8905%;\"\u003e\n \u003cp\u003e0.90\u0026le;ICC＜0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e（33.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e（11.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（22.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.837606837606837%\" valign=\"top\" style=\"width: 3.857%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（22.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.367521367521366%\" valign=\"top\" style=\"width: 12.8905%;\"\u003e\n \u003cp\u003e0.85\u0026le;ICC＜0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.837606837606837%\" valign=\"top\" style=\"width: 3.857%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.367521367521366%\" valign=\"top\" style=\"width: 12.8905%;\"\u003e\n \u003cp\u003e0.80\u0026le;ICC＜0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（11.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.837606837606837%\" valign=\"top\" style=\"width: 3.857%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（3.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.367521367521366%\" valign=\"top\" style=\"width: 12.8905%;\"\u003e\n \u003cp\u003eICC＜0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（11.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.837606837606837%\" valign=\"top\" style=\"width: 3.857%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e（3.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.367521367521366%\" valign=\"top\" style=\"width: 12.8905%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 10.6575%;\"\u003e\n \u003cp\u003e(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.698005698005698%\" valign=\"top\" style=\"width: 4.06%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.837606837606837%\" valign=\"top\" style=\"width: 3.857%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.675213675213675%\" valign=\"top\" style=\"width: 9.2365%;\"\u003e\n \u003cp\u003e(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 Frequency of the difference in mean values for difference among measurement (mm) and for reproducibility of the measurement method (mm)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"656\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.024353120243532%\" valign=\"bottom\" style=\"width: 4.7207%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.400304414003045%\" colspan=\"8\" style=\"width: 8.9388%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Among measurement\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.009132420091326%\" colspan=\"8\" style=\"width: 18.5505%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Reproducibility of the measurement method\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.024353120243532%\" rowspan=\"3\" style=\"width: 4.7207%;\"\u003e\n \u003cp\u003e\u003cem\u003eRange (mm)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.441400304414003%\" colspan=\"6\" style=\"width: 3.6862%;\"\u003e\n \u003cp\u003e\u003cem\u003eCoordinate difference\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.67579908675799%\" colspan=\"2\" style=\"width: 5.2527%;\"\u003e\n \u003cp\u003e\u003cem\u003e \u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.136986301369863%\" colspan=\"6\" style=\"width: 13.2979%;\"\u003e\n \u003cp\u003e\u003cem\u003eCoordinate difference\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.58904109589041%\" colspan=\"2\" style=\"width: 5.2527%;\"\u003e\n \u003cp\u003e\u003cem\u003e \u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.861423220973784%\" colspan=\"2\" style=\"width: 4.4548%;\"\u003e\n \u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.861423220973784%\" colspan=\"2\" style=\"width: 4.4548%;\"\u003e\n \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.299625468164795%\" colspan=\"2\" style=\"width: 4.4548%;\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.674157303370787%\" colspan=\"2\" style=\"width: 5.2527%;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.112359550561798%\" colspan=\"2\" style=\"width: 4.4548%;\"\u003e\n \u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.674157303370787%\" colspan=\"2\" style=\"width: 4.4548%;\"\u003e\n \u003cp\u003e\u003cem\u003eY\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.674157303370787%\" colspan=\"2\" style=\"width: 4.4548%;\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.797752808988765%\" colspan=\"2\" style=\"width: 5.2527%;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.201680672268908%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.983193277310924%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.201680672268908%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.983193277310924%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.201680672268908%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.352941176470588%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.831932773109243%\" style=\"width: 1.7287%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.142857142857143%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.201680672268908%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.352941176470588%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.201680672268908%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.983193277310924%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.201680672268908%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.773109243697479%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.831932773109243%\" style=\"width: 1.7287%;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.403361344537815%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e\u003cem\u003e(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.234234234234235%\" style=\"width: 4.7207%;\"\u003e\n \u003cp\u003e\u0026ge;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.6036036036036037%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.846846846846847%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e-22.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.6036036036036037%\" style=\"width: 0.9309%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n 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\u003c/td\u003e\n \u003ctd width=\"7.207207207207207%\" style=\"width: 3.5239%;\"\u003e\n \u003cp\u003e-100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\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":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4890919/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4890919/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo evaluate reliability and reproducibility of 3-dimensional (3D) assessment of maxillary protraction treatment using voxel-based superimposition of cone-beam computed tomography (CBCT) models of the anterior cranial base in growing patients with skeletal class III malocclusion.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCBCT scans were performed before and after maxillary protraction treatment for Class III malocclusion. Three observers independently constructed 162(27*2*3) 3D virtual models from CBCT scans, which had been reoriented 3D models before treatment to natural head posture, of 27 patients in software. The anterior cranial base was used to register the 3D models pre- and port- treatment. Three observers independently identified 9 landmarks(Including those in the contralateral side)and recorded in three-dimensional coordinates in the 3D models. Each observers performed this three times on the pre- and post-treatment model. The mean value of the 3 sets of coordinates at different times was taken as the coordinates for each landmark. The intraobserver reliability and inter-observer reproducibility of the method for craniomaxillary changes were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe ICCs was \u0026gt;\u0026thinsp;0.90 for 25 (92.6%) out of the total 27 intraobserver assessments. The precision of the measurement method was within 0.3 mm in 21 (77.8%) cases. The interobserver reproducibility errors were \u0026lt;\u0026thinsp;0.3 mm in 21 of the 27 cases (77.8%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe reliability and reproducibility of the method for assessment of maxillary protraction treatment in growing patients with skeletal Class Ⅲ malocclusion were judged to be excellent.\u003c/p\u003e","manuscriptTitle":"Reliability and Reproducibility of CBCT Assessment of craniomaxillary Changes Before and After Treatment for Class III Growing Patients – An convenient and intuitively Way for Evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 04:55:31","doi":"10.21203/rs.3.rs-4890919/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-21T05:03:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-20T07:43:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-19T13:20:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-08-10T09:06:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4a660deb-04d2-45e3-a3ae-1340a9aeaeb7","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:01:35+00:00","versionOfRecord":{"articleIdentity":"rs-4890919","link":"https://doi.org/10.1186/s12887-025-06049-x","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-10-09 15:57:47","publishedOnDateReadable":"October 9th, 2025"},"versionCreatedAt":"2024-10-15 04:55:31","video":"","vorDoi":"10.1186/s12887-025-06049-x","vorDoiUrl":"https://doi.org/10.1186/s12887-025-06049-x","workflowStages":[]},"version":"v1","identity":"rs-4890919","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4890919","identity":"rs-4890919","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}