Surgical planning: the challenge of three-dimensional soft tissue analysis

In maxillofacial surgery and orthodontics, planning precision has traditionally relied on cone beam computed tomography (CBCT). While this tool excels in visualizing bone structures, it has intrinsic limitations for soft tissue assessment, particularly the insufficient contrast of superficial skin and muscle structures. However, the patient's psychological acceptance of treatments and the adjustment of their expectations depend directly on the predictability of the facial aesthetic outcome. Until now, the practitioner often had to deal with a hybridization of 2D and 3D parameters, a source of bias and extrapolation errors during surgical planning.

This scoping review aims to map the anatomical landmarks and measurement protocols used in 3D facial photography between 2017 and 2025. The specific objective is to synthesize the available evidence to propose a structured and reproducible morphological analysis framework, named the "3D FullFace A" tool. The authors seek to answer a central clinical question: which three-dimensional anthropometric landmarks and measurements allow for an accurate characterization of facial morphology to overcome the shortcomings of conventional methods and secure orthodontic-surgical management.

Scoping review methodology

This study was conducted as a scoping review following the PRISMA-ScR guidelines and the Joanna Briggs Institute methodological framework. The objective was to map the measurement protocols and anatomical landmarks used in 3D facial photography for orthodontics and maxillofacial surgery.

The selection protocol was carried out as follows:

• Search strategy: Exploration of MEDLINE (PubMed), Scopus, SciELO, and Web of Science databases. The primary publication window spanned from 2017 to 2025, including references up to 2005 for fundamental anatomical landmarks.
• Inclusion criteria: Observational, clinical, and methodological studies focusing on human morphological analysis via 3D photography. Exclusively 2D or animal studies were excluded.
• Selection and extraction: A two-phase filtering process was performed by two independent examiners, with arbitration by a third reviewer in case of discrepancy.
• Final sampling: Out of 79 articles initially identified, 18 observational studies meeting the quality criteria were included in the final synthesis.

Les auteurs ont utilisé les données extraites pour développer l'outil analytique « 3D FullFace A », intégrant 13 points de la ligne médiane et 12 points bilatéraux pour générer 18 mesures linéaires et 28 mesures angulaires.

Literature review and development of the 3D FullFace A tool

Of the 79 articles initially identified in the MEDLINE, Scopus, SciELO, and Web of Science databases, this scoping review included 18 observational studies published between 2017 and 2025. The analysis of these data allowed for the synthesis of anatomical landmarks and measurement protocols, leading to the creation of a structured analysis framework named "3D FullFace A".

The tool developed is based on precise facial mapping including:

• Anatomical landmarks: 13 points located on the midline and 12 bilateral points.
• Linear metrics: 18 measurements for evaluating morphological distances.
• Angular metrics: 28 measurements dedicated to the analysis of facial proportions and convexity.

Identified clinical performance and applications

The synthesis of the 18 included studies highlights several key results regarding the use of 3D photography in orthognathic surgery and orthodontics:

• Technical reliability: The authors report that landmark identification via stereophotogrammetry is highly reproducible, surpassing the limitations of conventional 2D photography which often induces extrapolation bias.
• Soft tissue evaluation: Unlike cone beam computed tomography (CBCT), which offers limited contrast for superficial structures, 3D photography allows for precise quantification of post-operative soft tissue changes.
• Asymmetry analysis: The compiled data demonstrate increased efficiency in characterizing facial asymmetries and overall proportions, essential for surgical planning and managing patients' aesthetic expectations.

Although the included studies confirm the potential of 3D photography as a complementary tool to CBCT, the review highlights the previous absence of a standardized analysis protocol for facial soft tissues, a gap that the 3D FullFace A tool aims to fill.

Analysis of the 3D FullFace A: a turning point for tissue planning

The results of this scoping review highlight a major advancement for orthognathic surgery: the shift from bone-centered planning to a rigorous analysis of soft tissues. By synthesizing data from 18 observational studies, the authors developed the "3D FullFace A" tool. This protocol, structured around 13 midline points and 12 bilateral points, allows for the extraction of 18 linear measurements and 28 angular measurements. In the practice, this means that the practitioner finally has a normative framework to quantify facial asymmetry and proportionality with a precision that CBCT alone, limited by its low contrast of superficial tissues, cannot offer.

The study highlights a recurring error in current practice: the combination of 2D and 3D parameters, a frequent source of extrapolation bias. The stereophotogrammetry approach validated here resolves this issue by ensuring reliable identification of cutaneous anatomical landmarks. Clinically, this precision is decisive for managing patient expectations. By visualizing the tissue impact of bone movements, the surgeon can reduce pre-surgical anxiety and improve acceptance of post-operative results.

However, the study acknowledges limitations: the proposed framework remains preliminary and requires validation on a larger scale. Although anatomical landmarks are stable over time, the specific literature on 3D morphological analysis remains limited. For the implantologist or oral surgeon, these results suggest progressively integrating 3D photography as an essential complement to tomography for a global and objective facial analysis.

Study summary

This literature review, including 18 observational studies, validates stereophotogrammetry as a gold standard tool for soft tissue analysis, where CBCT remains limited. The authors synthesized these data to create the "3D FullFace A" tool, integrating 25 anatomical landmarks (13 median and 12 bilateral) allowing for 18 linear measurements and 28 precise angular measurements.

In concrete terms, for the practitioner:

• Optimize your planning: use 3D photography as a systematic complement to CBCT to quantify asymmetries and soft tissue changes, which are invisible on bone structures alone.
• Improve patient acceptance: rely on the 46 standardized measurements of the "3D FullFace A" tool to objectify expected results, allowing for the adjustment of aesthetic expectations and the reduction of pre-operative anxiety.
• Standardise your analyses: adopt this framework of reproducible measurements for the longitudinal follow-up of complex orthodontic treatments and facial feminisation or masculinisation surgeries.

Technical lexicon of the study

Stereophotogrammetry: 3D image capture method used for the reliable identification of facial landmarks, offering a non-invasive alternative to radiographic examinations for soft tissue analysis.

3D FullFace A: Three-dimensional facial analysis tool developed in this study, integrating 13 midline points and 12 bilateral points for a systematized morphological evaluation.

Anatomical landmarks: Specific spatial coordinates (25 points selected here) serving as the basis for calculating linear and angular measurements to characterize facial morphology.

Cone Beam Computed Tomography (CBCT): Reference imaging technique for bone structures, cited here for its intrinsic limitations in terms of contrast and representation of superficial soft tissues compared to 3D photography.

Linear and angular measurements: Quantitative parameters (18 and 28 measurements respectively in the proposed protocol) allowing for the objective characterization of facial asymmetry and soft tissue proportionality.

Orthognathic surgery: Surgical discipline aimed at correcting maxillofacial deformities, for which 3D photography is presented as a promising tool for planning and predicting aesthetic results.

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