Three-dimensional Frankfort horizontal plane for 3D cephalometry: a comparative assessment of conventional versus novel landmarks and horizontal planes

Background: To assess the reproducibility of landmarks in three dimensions that determine the Frankfort horizontal plane (FH) as well as two new landmarks, and to evaluate the angular differences of newly introduced planes to the FH. Methods: Three-dimensional (3D) surface models were created from CBCT scans of 26 dry human skulls. Porion (Po), orbitale (Or), internal acoustic foramen (IAF), and zygomatico-maxillary suture (ZyMS) were indicated in the software by three observers twice with a 4-week interval. Angles between two FHs (FH 1: Or-R, Or-L, mid-Po; FH 2: Po-R, Po-L, mid-Or) and between FHs and new planes (Plane 1-6) were measured. Coordinates were exported to a spreadsheet. A statistical analysis was performed to define the landmark reproducibility and 3D angles. Results: Intra-and inter-observer landmark reproducibility showed mean difference more than 1 mm for x-coordinates of all landmarks except IAF. IAF showed significantly better reproducibility than other landmarks (P < 0.0018). The mean angular difference between FH 1 and FH 2 was 0.7 degrees. Plane 3, connecting Or-R, Or-L and mid-IAF, and Plane 4, connecting Po-R, Po-L and mid-ZyMS, both showed an angular difference of less than 1 degree when compared to FHs. Conclusions: This study revealed poor reproducibility of the traditional FH landmarks on the x-axis and good reproducibility of a new landmark tested to replace Po, the IAF. Yet, Or showed superior results compared to ZyMS. The potential of using new horizontal planes was demonstrated. Future studies should focus on identification of a valid alternative for Or and ZyMS and on clinical implementation of the findings.