International Congress Series 1256 (2003) 1235 1240

ACRO 4D: universal analysis for four-dimensional diagnosis, 3D planning and simulation in orthognathic surgery
R. Olszewski a,*, V. Nicolas b,1, B. Macq b,1, H. Reychler a,2
Catholic University of Louvain, UCL, Department of Oral and Maxillofacial surgery, 10, Avenue Hippocrate, 1200 Brussels, Belgium b Catholic University of Louvain, Communication and remote sensing Laboratory, Faculty of Engineering, vin, 1348 Louvain-la-Neuve, Belgium Place du Levant 2, Batiment Ste Received 10 March 2003; received in revised form 10 March 2003; accepted 11 March 2003
a

Abstract This new analysis permits to study different craniomaxillofacial malformations and facial asymmetry. The visualization of ACRO 4D analysis is done in 3D, understanding the results must be done in 4D (3D and time), which associates the Moss neural matrix theory and the Delaire ideal individual equilibrium concept. The ACRO 4D analysis contains 38 landmark points and 28 plans. Angles (5), surfaces (10) and volumes (9) can be measured. The ACRO 4D analysis has been decomposed in 16 modules and 6 standard planing procedures have been implemented by combining these modules. Ten of these modules represent the 2D to 3D transformations from 2D Delaire analysis. Six modules study the symmetry asymmetry of the different craniofacial regions. The ACRO 4D analysis guides the surgeon, step by step, to the diagnosis, with clear guidelines and 3D incorporated examples. The generic tools, developed in this software, can achieve the transformation of every 2D to 3D cephalometric analysis with the creation of the independent landmark points, lines, plans and volumes. Our further investigations are the validation of the method accuracy, the clinical validation on patients and development of 3D orthognathic surgery simulation based on this ACRO 4D analysis. D 2003 Published by Elsevier Science B.V.
Keywords: 3D cephalometry; Craniomaxillofacial surgery; Orthognathic surgery

* Corresponding author. Tel.: +32-2-764-57-12; fax: +32-2-764-58-76. E-mail addresses: raphael.olszewski@stom.ucl.ac.be (R. Olszewski), Vincent.Nicolas@tele.ucl.ac.be (V. Nicolas), macq@tele.ucl.ac.be (B. Macq), reychler@stom.ucl.ac.be (H. Reychler). 1 Tel.: +32-10-47-23-00; fax: +32-10-47-20-89. 2 Tel.: +32-2-764-57-12; fax: +32-2-764-58-76. 0531-5131/03 D 2003 Published by Elsevier Science B.V. doi:10.1016/S0531-5131(03)00215-2

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1. Introduction A new software for four dimensions diagnosis, three dimensions (3D) planning and 3D simulation for the use in orthognathic surgery is presented. The universal analysis could permit to study different craniomaxillofacial malformations, facial asymmetry and dentomaxillofacial dysmorphosis. The ACRO 4D analysis is universal because it offers the tools to transform every 2D cephalometric analysis into a 3D cephalometric analysis. This one could be used in association with the 3D planning and 3D simulation of orthognathic operations. The visualization of ACRO 4D analysis is done in 3D but understanding the results must be analysed in 4D (3D plus time), which associates the Moss neural matrix theory [1] and the Delaire ideal individual equilibrium concept [2]. The Moss theory and the Delaire equilibrium concepts are two different ways of understanding the dentomaxillofacial dysmorphosis and maxillofacial disorders and were in contradiction until today, because of thinking in the 2D space. The 2D cephalometric Delaire analysis was chosen as a starting point because this analysis is the only one, which studies the links between the entire skull and face structures. The diagnosis and planning in the 2D cephalometric Delaire analysis are based on the presence of an individual ideal equilibrium between the skull and the face. This equilibrium is represented by a geometric construction using landmark points and lines, found and drawn on a skull profile X-ray. The lines are linked together with theoretical laws and anthropologic ratios. All nonequilibrium in this geometrical system represents a single class of craniomaxillofacial dysmorphosis. All orthodontic and orthognathic treatment must tend to restore the individual ideal equilibrium in the geometrical system. Each patient has his own equilibrium but the fundamental rules are universal. The weakness of 2D Delaire analysis is the insufficient study of asymmetry in the craniomaxillofacial malformations and dentomaxillofacial disorders. The ACRO 4D analysis studies also these asymmetries. The study of the craniomaxillofacial symmetry is based, in part, on the Moss neural matrix theory.

2. Method Two dry skulls and one patient (Treacher-Collins disease) were scanned with a 3D helical CT Scanner (Marconi MX 8000), with slice thickness of 1 mm, pitch of 0.7 mm, 1 feed per rotation, field of view = 210 mm, matrix 512 512, 120 kV, 200 mA s. The data were stored in Dicom format. The 3D reconstruction of the 3D images was done into the ACRO 4D software. The software is based on Linux (Gnome 1.4); it uses the VTK opensource library [3] and the Tcl language. The 2D to 3D transforming of the 2D Delaire analysis begins with duplication of some landmark points. All of the landmark points chosen for the ACRO 4D analysis are visible on the 3D reconstruction of every skull. Some unique landmark points in 2D Delaire analysis become straight lines in the ACRO 4D analysis. All of the Delaire lines become plans in the third dimension. The rules, which link Delaire lines, link now plans. New plans are created to achieve a correct 3D geometrical construction. New angles and volumes appear between plans.

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Cranial nerve foramina serve as landmark points for plans, which study the craniomaxillofacial structures symmetry.

3. Results The ACRO 4D analysis contains 38 landmark points, 8 straight lines and 28 plans. Angles (5), surfaces (10) and volumes (9) can be measured. The ACRO 4D analysis has been decomposed in 16 study modules. Six standard planing procedures have been implemented by combining these modules. The number of modules varies from 16 to 1 module(s) per study planing procedure. Ten of the modules represent the 2D to 3D transformations from 2D Delaire analysis. Six modules study the symmetry asymmetry of the cranium base, the cranial vault, the medial floor of the face and of the mandible. In each module, 3 or 4 plans appear in the same time. They are superposed to the 3D reconstruction of the skull. The ACRO 4D analysis guides the surgeon, step by step, to the diagnosis, with clear guidelines and 3D incorporated examples. 3.1. A module: the study of cranial base The landmark points are: M point (right, left), union of naso-maxillo-frontal suture, Clp point (right, left), top of the clino d process posterior, Cla point (right, left), top of the clino d process anterior, Op pointOccipital posterior, SCT point (right, left), center of temporal condyle area and Cp point (right, left), mandible condyle posterior. The planes to create are C1superior plane of the cranial base and C2the craniofacial border. The a angle is measured between C1/C2 planes. 3.2. B module: the study of clivus The landmark points are Od, the top of the odontoid process and Ma (right, left), lateral and external side of mastoid process. The plane to create is C4inclinated clivus plane. The b angle is measured between C1/C4 planes. The mastoid area (right, left) is measured on the C4 plane. 3.3. C module: the study of the cranial vault The landmark point is Sccranial vault top. A straight line OiOccipital inferior, appears. The planes to create are the vertical posterior plane and C3the cranial height. Two distances are measured: from Sc point on C3 plane to the intersection C3/C2, and from M line (M points right and left) to Oi line. 3.4. D module: the study of the symmetry of the cranial base The landmark points are Cg, the top of the crista galli process, SSO, the midpoint of the sphenooccipital synchondrosis and the cranial base points. These points

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are: foramen rotundum (right, left), foramen ovale (right, left), foramen spinosum (right, left), internal auditory meatus (right, left), foramen jugular (right, left) and hypoglossus canal (right, left). The Psm, medial sagittal plane is created. The volumetric presentation of cranial base symmetry (right, left) is done on its anterior, middle and posterior part. 3.5. E module: the study of the external symmetry of the calvaria The lateral cranial planes (right, left) are created to show the asymmetry of the parietal and temporal bones. 3.6. F module: the anterior plane of facial equilibrium The landmark points are Pts point, pterygoid superior, the entrance of foramen rotundum (right, left) to the pterygoid maxillary fossa, and FM point (right, left), junction of frontal-maxilla suture. Two planes are created: F1anterior plane of the facial equilibrium (right, left) and the tangent plane to the occipital bone (right, left). The u angle C1/F1 is statistical (85j for child and female, 90j for male and after growth period) or cranial-adapted = u statistical angle F parametric angular correction. The craniomaxillar areas (right, left) are measured. 3.7. G module: the middle and posterior plane of the facial equilibrium The landmark point is Pti point (right, left), junction between the pterygoid process and the maxilla tuberosity. The planes to create are F2the middle plane of facial equilibrium (right, left) and F3the posterior plane of facial equilibrium (right, left). The craniomandibular area (right, left), craniofacial area (right, left) and the craniovertebral area (right, left) are measured. The ratio right area/left area is measured. 3.8. H module: theoretical facial height The landmark point is Na, Nasion, junction of the nasal and frontal sutures. The position of NaVsegment (right, left), in front of the Na point, depends on the patient age and sex. The plane to create is F5the theoretical facial height. 3.9. I module: the cervical palatal plane The landmark points are Np (right, left), top of the nasal palatal canal and Notch (right, left), top of the pre-angular mandible notch. The segments created are: Goanatomic (right, left), the anatomic position of the mandible angle and ENA-theoretical (right, left). ENA is the anterior nasal spine. The planes to create are F4, cervical palatal plane (right, left), A and B planes (right, left), and the secant A/B plane (right, left). To choose between optional and nonoptional F4 planes (right, left) depends on different parameters.

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3.10. J module: the anterior posterior equilibrium plane The segments to create are Pto, pterygoid odontoid, segment (right, left) and Gotheoretical, theoretical position of the mandible angle (right, left). The plane to create is F6the anterior posterior equilibrium plane (right, left). It is possible to study the different positions of the mandible angle (right, left). 3.11. K module: the study of the midfacial floor symmetry, in sagital and coronal orientation The landmarks are Canine point (right, left), fos-superior orbital fissure (right, left), FM point (right, left), fm point, external fronto-zygomatic point (right, left) and molar point (right, left). The planes to create are canine (right, left), zygomatic (right, left) and lateral-zygomatic (right, left) planes. The angles are measured between these planes and the Psm plane. The ratio of each right side/left side angle for each plane are measured. 3.12. L module: the symmetry study of the midfacial floor, transverse orientation The landmark points are Suso point (right, left)supra-orbital foramen and Souso point (right, left)infra-orbital foramen. The planes to create are the supra-orbital (right, left) and infra-orbital (right, left) planes. The orbital and sinusal (right, left) areas are measured. 3.13. M module: the midfacial floor volumes The orbital, maxilla sinus and nasal cavity volumes are measured (right, left and right/ left ratios). 3.14. N module: the theoretical mental position The MetVsegment (right, left) and MetVplane (right, left) are created. The face is divided into two parts. The distance between NaVsegment and ENA-theoretical segment represents 45% of the total distance between NaVsegment and MetV segment. 3.15. O module: theoretical occlusal plane creation The Om (occipital-mastication) segment is created. The planes to create are F7, the mandibular basilar plane (right, left) and F8theoretical occlusal plane (right, left). The center of MetV segment and Pto segment is calculated. 3.16. P module: the study of mandible symmetry The landmark points are: mental foramen point (right, left) and Spix point (right, left). The planes to create are lateral mental (right, left), lateral condylar (right, left)and

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lateral Spix (right, left) planes. The distances and ratios right/left between the same planes (right, left) are measured. Using the generic tools, developed in this software, it is possible to achieve every 2D to 3D cephalometric analysis with the creation of the independent landmark points, segments, lines, distances, plans, areas, angles and volumes.

4. Discussion The ACRO 4D software and analysis takes a possibility to transform all of the 2D cephalometries to the new age of the 3D cephalometry. Our further investigations are the validation of the method accuracy, the clinical validation on patients and development of 3D simulation based on this ACRO 4D analysis.

Acknowledgements gion Wallonne, Waleo, Herol Project No. 215 132, This work is supported by Re 2002 2006.

References
[1] M.L. Moss, L. Salentijn, The primary role of the functional matrix in facial growth, Angle Orthod. 55 (1969) 566 574. oriques. Quelques [2] J. Delaire, Lanalyse architecturale et structurale cranio-faciale (de profil). Principes the exemples demploi en chirurgie maxillo-faciale, Rev. Stomatol. 79 (1) (1978) 1 33. [3] W.J. Schroeder, VTK: The Visualization Toolkit. Users Guide, Kitware, New York, 1998.