Midsagittal Plane First: Building a Strong Facial Reference Frame for Computer-Aided Surgical Simulation

Maggie K. Grissom, Jaime Gateno, Jeryl D. English, Helder B. Jacob, Tianshu Kuang, Carla E. Gonzalez, Peng Yuan, Hannah H. Deng, Caleb J. Frick, Daeseung Kim, Abdullahi Hassan, James J. Xia

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


PURPOSE: A facial reference frame is a 3-dimensional Cartesian coordinate system that includes 3 perpendicular planes: midsagittal, axial, and coronal. The order in which one defines the planes matters. The purposes of this study are to determine the following: 1) what sequence (axial-midsagittal-coronal vs midsagittal-axial-coronal) produced more appropriate reference frames and 2) whether orbital or auricular dystopia influenced the outcomes.

METHODS: This study is an ambispective cross-sectional study. Fifty-four subjects with facial asymmetry were included. The facial reference frames of each subject (outcome variable) were constructed using 2 methods (independent variable): axial plane first and midsagittal plane first. Two board-certified orthodontists together blindly evaluated the results using a 3-point categorical scale based on their careful inspection and expert intuition. The covariant for stratification was the existence of orbital or auricular dystopia. Finally, Wilcoxon signed rank tests were performed.

RESULTS: The facial reference frames defined by the midsagittal plane first method was statistically significantly different from ones defined by the axial plane first method (P = .001). Using the midsagittal plane first method, the reference frames were more appropriately defined in 22 (40.7%) subjects, equivalent in 26 (48.1%) and less appropriately defined in 6 (11.1%). After stratified by orbital or auricular dystopia, the results also showed that the reference frame computed using midsagittal plane first method was statistically significantly more appropriate in both subject groups regardless of the existence of orbital or auricular dystopia (27 with orbital or auricular dystopia and 27 without, both P < .05).

CONCLUSIONS: The midsagittal plane first sequence improves the facial reference frames compared with the traditional axial plane first approach. However, regardless of the sequence used, clinicians need to judge the correctness of the reference frame before diagnosis or surgical planning.

Original languageEnglish (US)
Pages (from-to)641-650
Number of pages10
JournalJournal of Oral and Maxillofacial Surgery
Issue number4
StatePublished - Apr 2022


  • Anatomic Landmarks
  • Computers
  • Cross-Sectional Studies
  • Facial Asymmetry
  • Humans
  • Imaging, Three-Dimensional/methods

ASJC Scopus subject areas

  • Oral Surgery
  • Surgery
  • Otorhinolaryngology


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