ORIGINAL ARTICLE

J. Djordjevic M. Jadallah A. I. Zhurov A. M. Toma S. Richmond

Three-dimensional analysis of facial shape and symmetry in twins using laser surface scanning

Authors' afliation: J. Djordjevic, M. Jadallah, A. I. Zhurov, A. M. Toma, S. Richmond, Department of Applied Clinical Research and Public Health, Cardiff University Dental Hospital, Cardiff, Wales, UK Correspondence to: Dr Jelena Djordjevic Department of Applied Clinical Research and Public Health Cardiff University Dental Hospital, 1st oor, room 112, Heath Park, Cardiff, CF14 4XY, Wales UK E-mail: alexmjz@ptt.rs

Djordjevic J., Jadallah M., Zhurov A. I., Toma A. M., Richmond S. Three-dimensional analysis of facial shape and symmetry in twins using laser surface scanning Orthod Craniofac Res 2012. 2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd Structured Abstract Objectives Three-dimensional analysis of facial shape and symmetry in twins. Setting and Sample Population Faces of 37 twin pairs [19 monozygotic (MZ) and 18 dizygotic (DZ)] were laser scanned at the age of 15 during a follow-up of the Avon Longitudinal Study of Parents and Children (ALSPAC), South West of England. Material and Methods Facial shape was analysed using two methods: 1) Procrustes analysis of landmark congurations (63 x, y and z coordinates of 21 facial landmarks) and 2) three-dimensional comparisons of facial surfaces within each twin pair. Monozygotic and DZ twins were compared using ellipsoids representing 95% of the variation in landmark congurations and surface-based average faces. Facial symmetry was analysed by superimposing the original and mirror facial images. Results Both analyses showed greater similarity of facial shape in MZ twins, with lower third being the least similar. Procrustes analysis did not reveal any signicant difference in facial landmark congurations of MZ and DZ twins. The average faces of MZ and DZ males were coincident in the forehead, supraorbital and infraorbital ridges, the bridge of the nose and lower lip. In MZ and DZ females, the eyes, supraorbital and infraorbital ridges, philtrum and lower part of the cheeks were coincident. Zygosity did not seem to inuence the amount of facial symmetry. Lower facial third was the most asymmetrical. Conclusion Three-dimensional analyses revealed differences in facial shapes of MZ and DZ twins. The relative contribution of genetic and environmental factors is different for the upper, middle and lower facial thirds. Key words: 3D imaging; ALSPAC; face; shape analysis; surface laser scanning; symmetry; twins

Date: Accepted 6 November 2012 DOI: 10.1111/ocr.12012 2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd

Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Introduction
From the pioneering work of Francis Galton (1) to the modern-day human genome (2) and phenome projects (3), genetic and environmental determinants of craniofacial morphology have not ceased to intrigue scientists. Research efforts have been supported by the clinical interest of orthodontists in altering unfavourable facial growth. The success of such undertaking would depend on the possibility to inuence facial hard and soft tissues within genetic limitations. In the last few decades, heritability of facial features has been investigated through twin (49) and family studies (1014), which shed some light on this complex research area. However, individual genetic variants that affect normal variation in human facial features have yet to be identied (15). The majority of twin studies in orthodontics have relied on two-dimensional data collected from lateral cephalograms of participants. Small number of landmarks has been used to describe facial hard tissue morphology. Linear distances between landmarks have been used as an estimate of facial size and the angles between intersecting lines drawn between landmarks as an estimate of facial shape (16). It is clear that most information about the facial shape has been simply ignored (17). Three-dimensional imaging capture techniques have the potential to overcome some of the drawbacks of two-dimensional studies (17, 18). One of the rst three-dimensional studies exploring facial morphology of twins was performed by Burke (19). Using stereophotogrammetry, he analysed 13 parameters on facial contour maps of 18 twin pairs and concluded that dizygotic (DZ) twin pairs had larger mean intrapair differences in facial parameters than the monozygotic (MZ) pairs. The author identied important facial parameters to distinguish between the two groups and used them to calculate a facial similarity index. Investigations of three-dimensional symmetry in twins have also started with stereophotogrammetry. In a 9-year longitudinal study, three pairs of bilateral facial parameters were measured in six pairs of MZ twins (20). The authors found 2 |

that asymmetry was very small, amounting at most to a few millimetres, and not much larger than the measuring error of the method. Asymmetry could not be related to twin zygosity, adolescence or age. More recent studies have used laser surface scanning to capture three-dimensional facial data of twins. Naini and Moss (21) analysed faces of 10 MZ twin pairs and 16 DZ twin pairs using two methods. Analysis of 28 interlandmark distances revealed signicant genetic determination for midfacial parameters. The second method (analysis of facial surface shape) showed the strongest genetic determination for a triangular area of the midface encompassing the orbital rims, intercanthal area and nose. The authors also concluded that the concordance for vertical and anteroposterior facial parameters was greater in MZ twins than in DZ twins. Moss (22) analysed 10 MZ and 10 DZ twin pairs using the xed optical surface scanner. Facial surfaces of MZ twins exhibited similarities in shape of the brows, bridge of the nose and infraorbital ridges, whereas the lower parts of the face (cheeks, chin, and lips) were considerably different. In DZ twins, the areas around the eyes were different in shape as well as the lower part of the face. Three-dimensional analyses of facial characteristics of twins are rare and suffer from small, unrepresentative samples, with a wide age range and different ethnicity. Therefore, the aim of this study was to analyse three-dimensional facial shape and symmetry of MZ and DZ twins, identied from a cohort of 15-year-old white British adolescents, using a non-invasive laser surface scanning.

Material and methods

Participants

Participants were recruited from the Avon Longitudinal Study of Parents and Children (ALSPAC), a UK-based longitudinal birth cohort study designed to explore genetic and environmental inuences on health and well-being (23). All pregnant women resident in the old administrative county of Avon (centred around the city of Bristol in the South West of England), and their resulting

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Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Table 1. Characteristics of the study sample Monozygotic twins Age (months) N (pairs) Males Females 9 10 Mean (SD) 184.6 (1.4) 184.8 (1.8) Range 183187 182188 182188 Males Females Mixed Total 19 184.7 (1.6) Total N (pairs) 7 3 8 18 Dizygotic twins Age (months) Mean (SD) 183.4 (1.2) 185.3 (1.4) 186.0 (2.3) 184.9 (2.1) Range 182185 184187 184191 182191

children were eligible to participate in ALSPAC if their estimated delivery date fell between 1 April 1991 and 31 December 1992 inclusive (23, 24). Of the initial 14 541 pregnancies, all but 69 had known birth outcome. Of these 14 472 pregnancies, 14 062 were live births and 13 988 were alive at 1 year. The total number of twin pairs in the ALSPAC study sample is 204 (24). During 2006 and 2007, invitations to attend the annual recall clinic were sent to 9985 15-year-old adolescents. Of 5253 adolescents who attended, 4784 facial scans were collected. After exclusion of poor-quality scans and those with obvious facial dysmorphology, facial scans of 4747 adolescents (2233 males and 2514 females) were retained (25). Among these, 43 twin pairs were identied based on their mothers reports to the questionnaires. Zygosity was checked using genetic testing. DNA samples were not available for six twin pairs, and therefore, these were excluded from the analyses. The nal sample consisted of 37 twin pairs, 19 MZ pairs (nine malemale and 10 female-female) and 18 DZ pairs (seven male-male, three female-female and eight mixed). The mean age of MZ twins was 184.7 (SD 1.6) months and the mean age of DZ twins was 184.9 (SD 2.1) months (Table 1). The study was approved by the ALSPAC Ethics and Law Committee and the Local Research Ethics Committee. The consent forms were signed by the parents.
Laser scanning

system (series Vivid 700, 900, and 910) were tested and proved suitable for clinical applications (2631). Participants were instructed to sit still on a stool with adjustable height, 135 cm in front of the mirror placed between the scanners. They were told to adopt neutral expression, with relaxed facial musculature. Natural head position was obtained by asking them to look at the mirror and level their eyes to the horizontal mark on the mirror (by adjusting the stool height), and to level their facial midline to the vertical mark on the mirror (by moving the stool slightly left or right). They were also asked not to wear any make-up on the day of scanning, and had to take off the hats and glasses. Also, any hair overlying the face had to be moved away by a hairband or tightened by hairpins. Prior to scanning, participants were told to swallow hard (in order to bring their mandible in rest position) and close their lips. All twins fullled these requests. The scanning took approximately 8 s. If the person incidentally moved, smiled or changed facial expression, scanning was repeated. Mediumrange lenses with a focal length of 14.5 mm were used. Scanning was controlled by MultiScan software (Cebas Computer, GmBH, Eppelheim, Germany). For each participant, two les in VIVID format were obtained, which contained left and right facial halves. The data were saved on the computer memory for further analysis.
Processing of facial scans

Two laser scanning devices Vivid 900 (Konica Minolta Sensing Europe, Milton Keynes, UK) were used. Accuracy and reliability of this

Facial images were imported into Rapidform 2006 (INUS Technology Inc., Seoul, South Korea) and processed using an in-house-developed
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Djordjevic et al. 3D analysis of facial shape and symmetry in twins

subroutine. This technique has been tested on a plaster cast face, several adults and 40 children (3234). The raw data imported represents a cluster of a large number of unconnected shells. The term shell is used by the software to denote a triangulated surface or several surfaces treated as one (32). Therefore, the cluster rst had to be separated into shells, and then all irrelevant shells removed (background objects, bits of clothes, hair, ears and neck). The raw face obtained by scanning has a rough surface and therefore was smoothed, while preserving shape and volume (32). The next step was registration of the two facial halves using the best-t algorithm. The quality of the scans was checked prior to merging facial halves. Only scans that fullled the criteria of at least 70% matching in the overlap area within 0.5 mm, and at least 95% matching within 1 mm, were further processed (35). Finally, the holes in the surface meshes were lled in (eyebrows, eyes, nostrils) and two facial halves were merged (32). Prior to any analysis, the position of faces needed to be standardized. It was accomplished by tting them into the same reference frame, with the point halfway between the inner canthi of the eyes as the origin. Coronal plane (xy) was determined by the cylinder that tted all data points of the original-mirror face structure and therefore was based on the natural head position registered during the scanning. Sagittal plane (yz) was passing through the middle of the face. It was determined as the symmetry plane of the original-mirror face structure. Transverse plane (xz) was passing through the inner canthi of the eyes and was perpendicular to previous two planes. Standardisation of the faces was fully automated (17). Twenty-one facial landmarks, as dened by Farkas (36), were manually identied on the facial scans by one experienced operator (Fig. 1). For each face, 63 coordinates (x, y and z coordinates of 21 facial landmarks) were recorded and saved.
Facial shape analysis

Fig. 1. Anthropometric landmarks that were identied on the facial scans. (1) Glabella (g); (2) Nasion (n); (3) Endocanthion left (enl); (4) Endocanthion right (enr); (5) Exocanthion left (exl); (6) Exocanthion right (exr); (7) Palpebrale superius left (psl); (8) Palpebrale superius right (psr); (9) Palpebrale inferius left (pil); (10) Palpebrale inferius right (pir); (11) Pronasale (prn); (12) Subnasale (sn); (13) Alare left (all); (14) Alare right (alr); (15) Labiale superius (ls); (16) Crista philtri left (cphl); (17) Crista philtri right (cphr); (18) Labiale inferius (li); (19) Cheilion left (chl); (20) Cheilion right (chr); (21) Pogonion (pg). Denitions by Farkas (36) were used.

Facial shape analysis was performed using two methods: landmark-based and surface-based. 4 |
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Similarities and differences in facial shape within- and between-twin pairs were explored. For within-pair comparisons, the data was collected only from the same gender twins: 19 MZ pairs (nine male-male and 10 female-female) and 10 DZ pairs (seven male-male and three female-female). Eight pairs of DZ mixed twins were excluded from this analysis, as previous three-dimensional study showed that there is a gender difference in facial shape of 15.5-year-old ALSPAC adolescents (35). The rst method (landmark-based) comprised Generalized Procrustes Analysis (GPA), which was used to register (align) the sets of 21 facial landmarks by removing translation and rotation (37, 38). As facial form consists of size and shape, size differences were removed by scaling, separately for males and females in the sample. Within each twin pair, two landmark congurations were compared and the overall similarity in facial shape measured as the Procrustes

Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Fig. 2. The colour map and the histogram show the differences in three-dimensional facial shape of two monozygotic female twins. Faces of twins were scaled to the average Procrustes size for females (calculated from 21 facial landmarks) and superimposed in Rapidform 2006 (Inus Technology Inc., Seoul, South Korea) using best-t algorithm. The average distance between the two facial surfaces was 0.73 mm (calculated using internally developed subroutine) and the coincidence within 0.5 mm tolerance level was 41.42% (grey area on the colour map). Shades of blue (minimum value 1.96 mm) represent negative difference for the face of the rst twin (which is a reference) and the shades of red represent positive difference (maximum value 3.98 mm). Dotted lines on the middle image (which connect inner corners of the eyes and corners of the mouth) divide the face into the upper, middle and lower thirds.

distance. The lower the Procrustes distance between the two landmark congurations, the more similar facial shapes of two twins were. In order to visualize the differences between MZ and DZ twins, four sets of ellipsoids were constructed for: MZ males (n = 18), MZ females (n = 20), DZ males (n = 22, 14 from male-male and eight from mixed pairs) and DZ females (n = 14, six from female-female and eight from mixed pairs). Each ellipsoid represented 95% of the variation (two standard deviations from the mean) in a position of a given facial landmark. Landmark congurations were aligned on midendocanthion (a point halfway between the inner canthi of the eyes) and compared. The second method (surface-based) consisted of comparison of faces using all available data points (several thousands) captured by the laser scanning device. As in the rst method described, the faces were rst scaled to the average Procrustes size calculated from the landmarks (for males and females separately). The two faces of twins were then superimposed using best-t registration, a standard tool in Rapidform 2006, based on the iterative closest point algorithm. Absolute distances between all pairs of points of the two superimposed facial surfaces were automatically collected and the average distance between them calculated. The lower the average distance between the two facial surfaces,

the more similar facial shapes of two twins were. In addition, coincidence of the two faces was expressed as a percentage. A colour deviation map and a histogram were generated for each twin pair to visualize and quantify the differences in two facial shapes (Fig. 2). The same two parameters were obtained for the upper, middle and lower facial thirds. The upper third was located above a horizontal line connecting inner corners of the eyes (endocanthion left and right). The middle third occupied the area between the horizontal line connecting inner corners of the eyes and a horizontal line connecting corners of the mouth (cheilion left and right). The lower third was located below the horizontal line connecting corners of the mouth. The differences between MZ and DZ twins were analysed using average faces. These were constructed for the aforementioned groups of twins: MZ males (n = 18), MZ females (n = 20), DZ males (n = 22, 14 from male-male and eight from mixed pairs), and DZ females (n = 14, six from female-female and eight from mixed pairs). Iterative averaging in the local normal direction to a template was performed using another internally developed subroutine for Rapidform 2006. This ensured that the line of averaging met all faces at nearly right angles, thus providing maximum accuracy (17). Three iterations were performed. The average faces were aligned on
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Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Fig. 3. The colour map and the histogram show three-dimensional facial symmetry in a 15-year-old monozygotic male. The original face (left) and the mirror face (right) were superimposed (best-t registered) in Rapidform 2006 (Inus Technology Inc., Seoul, South Korea). The average distance between the original and the mirror faces was 0.84 mm (calculated using internally developed subroutine) and the coincidence within 0.5 mm tolerance level was 63.15% (represented by grey area on the colour map). Shades of blue (minimum value 2.07 mm) and shades of red (maximum value 2.13 mm) represent asymmetrical parts of the face.

the mid-endocanthion. The differences in facial shape of MZ and DZ twins were visualized and quantied on colour maps and histograms, respectively.
Facial symmetry analysis

Facial symmetry analysis was performed using aforementioned in-house-developed subroutine for Rapidform 2006. In this part of the study, only the three-dimensional facial surface was considered. For each participant, the amount of three-dimensional symmetry was calculated after superimposing (best-t registering) the original face with its mirror image (Fig. 3). The average distance between the original and the mirror faces and the percentage of coincidence were measured for the whole face, the upper, middle and lower facial thirds, as previously described (39, 40). The data was collected from all participating twins.
Error of the method

< 0.5 mm was considered insignicant and was therefore chosen as the tolerance level. The quality of facial scans was compared within and between MZ and DZ pairs. In order to examine the intra-operator reliability in landmark identication, facial scans of 30 individuals (15 males and 15 females) were randomly selected from the nal sample of 74 twins and landmarked on two occasions, 2 weeks apart. The reliability of the landmarks was determined using BlandAltman plots, as described previously (41).
Statistical analysis

An earlier study has shown that the Vivid 900 scanner is accurate to a level of 0.56 0.25 mm and that the error in computerized registration of left and right scans is 0.13 0.18 mm (26). In all facial surface comparisons, any difference 6 |
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Procrustes analysis was performed in R project, the open source software. Mean and standard deviations of all landmarks in the x-, y- and z-directions were calculated after scaling male and female subsamples. The distribution of all other data was checked using histograms, Q-Q plots and ShapiroWilk test. As the distribution was not normal and the subsamples were relatively small, the transformation of the data was not attempted. The data is presented as median and interquartile range (25th percentile, 75th percentile). Non-parametric MannWhitney U test was used for all comparisons between MZ and DZ twin pairs. The upper, middle and lower facial thirds within twin pairs were compared using

Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Table 2. Within-pair comparisons of facial shapes in monozygotic and dizygotic twins assessed by landmark-based and surface-based methods Monozygotic twins 25th Parameter Landmark-based method Pr. dist. (mm) Males Females All Surface-based method Av. dist. (mm) Males Females All Coincid. (%) Males Females All 9 10 19 9 10 19 0.87 0.77 0.82 38.94 43.00 39.39 0.74 0.63 0.73 36.46 31.45 36.43 0.99 1.12 1.04 41.98 51.66 44.08 7 3 10 7 3 10 1.30 1.30 24.84 24.80 1.12 1.12 21.86 18.62 1.51 1.60 29.55 30.93 0.001 <0.001 0.001 <0.001 9 10 19 9.86 9.86 9.31 9.19 9.20 7.48 11.99 11.51 10.44 7 3 10 10.73 10.71 10.53 10.37 13.76 14.16 0.233 (NS) 0.004 N Median perc. 75th perc. N Median Dizygotic twins 25th perc. 75th perc. p Value

N, number of within-pair observations; perc., percentile; Pr. dist., Procrustes distance between two landmark congurations within a twin pair; Av. dist., average distance between the two faces of twins; Coincid., the percentage of coincidence between the two faces of twins (see text and Fig. 2 for further explanation). Eight mixed dizygotic pairs were excluded from the analysis (see text for further explanation) and the data for dizygotic females were not analysed separately due to only three observations. NS, not statistically signicant. MannWhitney U test was performed.

KruskalWallis one-way analysis of variance test. When a statistically signicant difference was noticed, MannWhitney U test was used to explore it further. P value <0.05 was considered statistically signicant. These statistical analyses were performed in the Statistical Package for Social Sciences Software version 17.0 (SPSS Inc., Chicago, IL, USA).

Results
There was no statistically signicant difference in the quality of the scans within and between the twin groups (p > 0.05). Landmark identication error was <1 mm for majority of landmarks coordinates. The results of both analyses (landmark-based and surface-based) showed greater similarity of facial shape within MZ twin pairs in comparison with DZ twin pairs (Table 2). Landmark-based analysis revealed that there was an overlap in the interquartile ranges (25th to 75th percentile) for Procrustes distances of landmark congurations between

MZ and DZ males. However, according to the surface-based method, the interquartile ranges for similarity of facial shapes of the two twin groups were distinct and no overlap could be noticed. Further investigation revealed that within MZ male pairs lower facial third was the least similar, whereas in females, no such difference was noticed (Table 3). In DZ male pairs, the upper facial third was the most similar. The same analysis was not performed separately for females due to only three observations. When the data for DZ males and females were combined, the results showed that lower facial third was the least similar within DZ twin pairs. Facial shape of MZ and DZ twins was compared separately for males and females. After scaling and generalized Procrustes registration, the results showed that standard deviations of 21 facial landmarks were very similar between MZ and DZ twins (Tables 4 and 5). This is illustrated on ellipsoid plots, which represent 95% of the variation in landmark congurations (Fig. 4).
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Table 3. Facial shape similarity by facial thirds within monozygotic and dizygotic twin pairs Upper facial third 25th Twins MZ males N 9 Parameter Av. dist. (mm) Coincid. (%) MZ females 10 Av. dist. (mm) Coincid. (%) MZ all 19 Av. dist. (mm) Coincid. (%) DZ males

Middle facial third 75th perc. 0.93 46.13 1.00 55.78 0.92 51.80 1.22 45.63 1.47 38.29 Median 0.80 41.18 0.72 43.96 0.79 41.18 1.56 19.95 1.64 19.25 25th perc. 0.74 36.24 0.66 28.24 0.70 35.24 1.05 14.66 1.03 15.55 75th perc. 0.97 42.31 1.30 48.80 0.98 47.06 1.78 31.72 1.79 31.91

Lower facial third 25th Median 0.98 28.60 0.80 37.32 0.93 32.99 1.57 17.34 1.79 17.34 perc. 0.79 26.34 0.70 21.20 0.75 25.30 1.27 11.28 1.36 13.15 75th perc. 1.34 36.34 1.35 44.47 1.27 41.99 1.89 22.70 2.00 21.98 p Value 0.188 (NS) 0.032 0.384 (NS) 0.325 (NS) 0.140 (NS) 0.064 (NS) 0.019 0.010 0.013 0.030

Median 0.80 36.85 0.67 47.51 0.78 42.05 0.90 32.67 1.11 29.62

perc. 0.65 34.98 0.53 33.18 0.56 35.40 0.68 26.90 0.81 20.59

Av. dist. (mm) Coincid. (%)

DZ females

Av. dist. (mm) Coincid. (%)

DZ same gender

10

Av. dist. (mm) Coincid. (%)

N, number of within-pair observations; perc., percentile; MZ, monozygotic; DZ, dizygotic; Av. dist., average distance between the two faces of twins in a given facial third; Coincid., the percentage of coincidence between the two faces of twins in a given facial third. NS, not statistically signicant. Figures in bold indicate facial third which was signicantly different from the other two (MannWhitney U test was applied). KruskalWallis test was performed. The data for dizygotic females were not analysed separately due to only three observations. Eight mixed dizygotic pairs were excluded from the analysis (see text for further explanation).

Average faces of MZ and DZ twins of both genders are presented in Fig. 5. Monozygotic males tend to have wider face and nose with prominent upper lip when compared with DZ males, with a maximum difference of 1.8 mm. On the other hand, DZ males tend to have more prominent eyes, upper part of the forehead and central part of the chin, with a maximum difference of 1.2 mm. The two average male faces coincide 34.1%, mainly in the forehead, supraorbital and infraorbital ridges, the bridge of the nose and lower lip. Monozygotic females tend to have wider lower part of the face, wider nose and more prominent lips when compared with DZ females, with a maximum difference of 1.5 mm. Dizygotic females tend to have more prominent forehead, the bridge of the nose, malar area and lower part of the chin, with a maximum difference of 1.1 mm. The two average female faces coincide 61.1%, mainly in the eyes, supraorbital and infraorbital ridges, philtrum of the upper lip and lower part of the cheeks. 8 |
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Three-dimensional symmetry analysis showed that there was no statistically signicant difference in the amount of facial symmetry between MZ and DZ twins (Table 6). When upper, middle and lower facial thirds were compared, lower facial third was found to be the most asymmetrical in both twin groups (Table 7).

Discussion
In this exploratory cross-sectional study, threedimensional facial shape and symmetry of 37 twin pairs was investigated using non-invasive laser surface scanning. Facial analysis was performed using two methods. The rst method was based on geometric morphometrics, which employs GPA to register (align) sets of landmark congurations. Although powerful, Procrustes registration is not an ideal technique to superimpose numerous faces, as it relies only on limited

Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Table 4. Mean and standard deviation of 21 facial landmarks in x-, y- and z-directions for monozygotic and dizygotic males after scaling and Generalized Procrustes registration Monozygotic males (N = 18) X Landmark Glabella (g) Nasion (n) Endocanthion left (enl) Endocanthion right (enr) Exocanthion left (exl) Exocanthion right (exr) Palpebrale superius left (psl) Palpebrale superius right (psr) Palpebrale inferius left (pil) Palpebrale inferius right (pir) Pronasale (prn) Subnasale (sn) Allare left (all) Allare right (alr) Labiale superius (ls) Labiale inferius (li) Crista philtri left (cphl) Crista philtri right (cphr) Cheilion left (chl) Cheilion right (chr) Pogonion (pg) Mean (SD) 0.07 (0.66) 0.29 (0.60) 16.92 (1.32) 16.76 (1.31) 44.54 (1.31) 45.14 (1.49) 31.09 (1.03) 31.22 (1.37) 31.25 (1.16) 31.14 (1.40) 0.09 (0.85) 0.38 (0.71) 17.29 (1.14) 17.06 (1.38) 0.13 (0.46) 0.04 (0.43) 6.17 (1.54) 6.42 (1.42) 24.05 (2.21) 24.44 (1.72) 0.13 (0.59) Y Mean (SD) 48.91 (1.68) 38.04 (1.35) 27.35 (0.61) 26.47 (0.88) 26.95 (0.96) 27.49 (1.20) 34.66 (0.94) 34.25 (0.96) 22.63 (1.06) 22.23 (1.00) 2.68 (2.10) 15.20 (1.85) 6.31 (1.06) 6.05 (0.99) 30.85 (1.14) 45.88 (2.22) 29.47 (1.18) 29.22 (1.19) 38.40 (0.96) 37.89 (0.98) 67.05 (2.99) Z Mean (SD) 4.41 (1.62) 3.54 (1.28) 12.34 (1.12) 11.34 (1.12) 18.57 (1.24) 18.53 (1.26) 8.83 (1.41) 7.75 (1.08) 10.68 (0.83) 10.70 (1.28) 26.48 (2.00) 12.06 (1.52) 5.68 (1.82) 6.01 (1.79) 12.85 (1.38) 8.24 (1.23) 12.26 (1.38) 12.09 (1.37) 3.03 (2.30) 2.91 (1.77) 1.05 (3.49) Dizygotic males (N = 22) X Mean (SD) 0.32 (0.74) 0.43 (0.66) 16.91 (1.15) 16.55 (1.17) 43.99 (2.19) 44.25 (1.89) 30.09 (1.51) 30.97 (1.42) 30.42 (1.64) 30.89 (1.45) 0.06 (0.80) 0.34 (0.59) 16.98 (1.63) 16.74 (1.39) 0.06 (0.39) 0.21 (0.40) 6.09 (1.16) 6.64 (1.17) 24.47 (2.13) 24.46 (2.13) 0.14 (0.50) Y Mean (SD) 48.58 (1.90) 38.12 (1.62) 27.58 (0.71) 27.70 (0.77) 27.29 (1.03) 28.02 (0.97) 34.48 (1.16) 34.66 (1.30) 22.76 (1.22) 22.87 (1.22) 2.97 (1.82) 15.42 (2.38) 6.74 (1.51) 6.91 (1.31) 30.93 (1.18) 46.33 (1.25) 29.07 (1.29) 29.05 (1.21) 38.75 (1.42) 38.81 (1.65) 67.07 (2.64) Z Mean (SD) 3.99 (1.97) 3.31 (1.48) 12.54 (1.05) 12.55 (1.47) 17.81 (1.97) 17.89 (1.49) 7.76 (1.10) 7.11 (1.42) 10.83 (1.25) 10.55 (1.19) 26.38 (2.04) 12.68 (1.86) 4.20 (1.07) 4.47 (1.70) 13.15 (0.88) 9.24 (1.48) 12.34 (0.90) 12.25 (0.84) 4.28 (1.77) 3.11 (1.44) 2.39 (2.46)

number of landmarks and therefore does not take into account other information available (17). This is certainly the case when laser scanning devices are used, as these can capture at least 40 000 points on the facial surface (42). These points do not have xed positions and hence cannot be used as landmarks (17). For this reason, the second method used in this study relied on the comparison of facial surfaces. Two different superimposition techniques were used and this requires further explanation. The rst method of superimposition (the bestt alignment) was performed to compare faces of twins within each pair. The presumption was that the faces of twins will be very much alike and that slight differences can be registered using this approach. The best-t method is based on the iterative closest point algorithm, a

built-in feature of the commercial software. Essentially, it is a mathematical least-squares method. Automatic comparison took into account all pairs of points on the facial surfaces captured by the devices (several thousands). We are unaware of any study, which specically investigated the reliability of this software tool, although it has been used before (17, 35, 42). There is a theoretical possibility that different piece of software would produce slightly different superimposition results. This could be investigated in future studies. The second method of superimposition was used to compare average faces of MZ and DZ twins. The faces were aligned on mid-endocanthion, the point halfway between the inner corners of the eyes. As previous research has shown, this point can be used as a relatively
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Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Fig. 4. The 95% of the variation in scaled 21 facial landmarks for 74 monozygotic and dizygotic 15-year-old twins. (A) Front (x and y coordinates) and prole view (y and z coordinates) for male facial landmarks (18 monozygotic males represented by light grey ellipsoids and 22 dizygotic males represented by dark grey ellipsoids). (B) Front (x and y coordinates) and prole view (y and z coordinates) for female facial landmarks (20 monozygotic females represented by light grey ellipsoids and 14 dizygotic females represented by dark grey ellipsoids). The data were aligned on the mid-endocanthion, a point halfway between the inner canthi of the eyes. For names of landmarks refer to Figure 1.

stable reference during facial growth (42). The expected level of similarity of facial features between MZ and DZ twins was less than within the twin pairs. In this case, the best-t approach would tend to decrease the difference between the average MZ and DZ faces. On the other hand, similarity that was demonstrated by superimposition on mid-endocanthion point had a greater chance of representing a true effect. Surface-based average faces have already been applied in orthodontics and maxillofacial surgery to illustrate facial anomalies, evaluate facial growth, analyse treatment effects, compare facial morphologies between genders and among different populations (17, 18, 25, 35). Both facial analyses (landmark-based and surface-based) revealed greater similarity of facial surfaces in MZ twins than in DZ twins. This is in agreement with previous studies (19, 21, 22). Instead of presenting only descriptive data (obtained from colour maps), facial shape similarity within twin pairs was further investigated by dividing the faces into thirds and analysing 10 |
Orthod Craniofac Res 2012

facial shape parameters statistically. In MZ males, the lower facial third was the least similar, whereas in MZ females, no statistically signicant difference was determined. In DZ males, upper facial third had the most similar shape within twin pairs. These ndings can indicate that the inuence of genetic and environmental factors and their interaction on soft tissue shape is not the same in all facial regions. The amount of three-dimensional facial symmetry measured in MZ and DZ twins was similar as the one measured in 270 singletons from the same population (40). The study failed to show signicant differences in facial symmetry between MZ and DZ twin groups. It can either be due to small sample size, which prevents detection of any difference (possible type II error) or an indication that facial soft tissue symmetry of healthy individuals is not under strong genetic control. The latter statement is supported by previous study (20). More studies with larger samples are needed to reach a de-

Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Fig. 5. Average faces for monozygotic and dizygotic 15-year-old twins. (A) Average face for 18 monozygotic males (left), average face for 22 dizygotic males (centre) and the colour map and the histogram (right), which show the difference in facial shape of the two male twin groups. (B) Average face for 20 monozygotic females (left), average face for 14 dizygotic females (centre) and the colour map and the histogram (right), which show the difference in facial shape of the two female twin groups. Average faces were aligned on mid-endocanthion, and monozygotic average face in both genders was taken as the reference. Shades of blue represent negative (minimum 2 mm), and shades of red positive differences (maximum 2 mm) in facial shape. Grey area represents the parts of two facial surfaces, which coincide within 0.5 mm (34.1% in males and 62.1% in females).

nite conclusion. Lower facial third was found to be the most asymmetric, contrary to the ndings of previous study on 270 singletons (40), which showed no statistically signicant difference in the amount of symmetry among upper, middle and lower facial thirds. There is no consensus in the literature on the most asymmetric part of the face (39, 40). One of the strengths of this study is that facial analysis was performed in a sample of twins of the same age, with conrmed zygosity, who were born and raised in the same geographical region. Hence, the sample was more homologous than in previous three-dimensional studies on facial morphology of twins. The accuracy of the laser scanning method enables quantication of even subtle differences in facial morphology and symmetry, which has not been feasible previously using two-dimensional data from photographs or lateral cephalograms. In order to use the full

potential of this technology, future studies on heritability of facial features will have to adopt some method of three-dimensional facial analysis. As with any observational study, there are some limitations. The sample comes from a longitudinal population-based study, in which twins constitute approximately 1.3% of the cohort (24). As facial laser scanning was organized only during one follow-up clinic, sample size could not be increased. In addition, many confounding factors could not be controlled. In facial analysis, some of these factors might be related to body mass index, medical conditions, orthodontic treatment and trauma. In future studies, these factors should be carefully monitored to ensure the consistency of the results. It has been argued that twin results need to be interpreted with great caution, and that other family relations should be taken into account,
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Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Table 5. Mean and standard deviation of 21 facial landmarks in x-, y- and z-directions for monozygotic and dizygotic females after scaling and Generalized Procrustes registration Monozygotic females (N = 20) X Landmark Glabella (g) Nasion (n) Endocanthion left (enl) Endocanthion right (enr) Exocanthion left (exl) Exocanthion right (exr) Palpebrale superius left (psl) Palpebrale superius right (psr) Palpebrale inferius left (pil) Palpebrale inferius right (pir) Pronasale (prn) Subnasale (sn) Allare left (all) Allare right (alr) Labiale superius (ls) Labiale inferius (li) Crista philtri left (cphl) Crista philtri right (cphr) Cheilion left (chl) Cheilion right (chr) Pogonion (pg) Mean (SD) 0.47 (0.65) 0.60 (0.64) 16.40 (0.95) 15.98 (1.11) 43.87 (1.85) 43.72 (1.95) 30.08 (1.17) 30.34 (1.51) 30.34 (1.34) 30.36 (1.47) 0.21 (0.73) 0.13 (0.57) 16.20 (1.51) 16.28 (1.02) 0.12 (0.29) 0.06 (0.40) 5.36 (0.80) 5.75 (0.63) 22.79 (2.09) 23.16 (2.54) 0.27 (0.54) Y Mean (SD) 48.65 (2.05) 37.59 (2.03) 25.89 (0.72) 26.40 (0.75) 25.33 (0.88) 27.01 (0.74) 33.40 (0.86) 33.98 (1.04) 21.25 (0.96) 21.96 (0.84) 2.49 (1.37) 15.28 (1.46) 7.01 (0.90) 6.87 (1.23) 29.07 (1.48) 45.20 (1.64) 27.68 (1.40) 27.41 (1.41) 38.10 (1.50) 37.53 (0.85) 64.84 (1.96) Z Mean (SD) 3.91 (1.33) 2.68 (1.26) 10.43 (0.82) 9.84 (0.75) 15.86 (1.39) 15.99 (1.59) 6.03 (1.54) 5.79 (1.31) 8.52 (0.96) 8.42 (1.06) 23.68 (2.02) 10.26 (1.68) 3.84 (0.96) 3.56 (0.88) 11.53 (1.26) 7.88 (1.07) 10.54 (1.05) 10.61 (1.10) 4.59 (1.54) 3.79 (1.59) 0.76 (2.68) Dizygotic females (N = 14) X Mean (SD) 0.27 (0.64) 0.35 (0.57) 16.99 (1.26) 16.17 (1.06) 43.28 (1.16) 43.30 (1.62) 30.00 (1.13) 29.99 (1.31) 30.22 (1.09) 29.96 (1.27) 0.15 (0.46) 0.08 (0.50) 15.81 (1.21) 15.78 (1.02) 0.10 (0.33) 0.02 (0.39) 5.34 (1.09) 5.86 (0.92) 23.65 (1.39) 24.14 (1.38) 0.53 (0.39) Y Mean (SD) 48.15 (1.48) 37.86 (1.77) 26.14 (0.63) 26.38 (0.82) 25.86 (0.51) 27.16 (0.57) 33.06 (1.13) 33.86 (1.27) 21.76 (0.88) 22.11 (0.77) 2.80 (1.49) 15.75 (1.28) 7.21 (1.24) 6.94 (1.54) 29.42 (1.35) 44.42 (1.83) 28.09 (1.19) 27.95 (1.02) 37.87 (1.34) 37.38 (1.64) 64.50 (1.45) Z Mean (SD) 4.39 (1.38) 3.60 (1.05) 10.73 (0.67) 10.03 (0.84) 15.67 (1.28) 15.80 (1.01) 7.47 (0.77) 6.82 (0.90) 8.51 (0.88) 8.29 (0.87) 24.86 (1.93) 11.23 (1.53) 3.74 (1.06) 3.45 (0.89) 11.49 (0.92) 7.41 (1.58) 10.74 (0.92) 10.70 (0.88) 5.38 (1.59) 5.02 (1.28) 2.12 (2.41)

Table 6. Three-dimensional facial symmetry in monozygotic and dizygotic twins Monozygotic twins Parameter Av. dist. (mm) Males Females All Coincid. (%) Males Females All N 18 20 38 18 20 38 Median 0.69 0.59 0.66 49.91 57.26 52.23 25th perc. 0.60 0.46 0.51 44.52 44.73 44.86 75th perc. 0.82 0.72 0.76 54.02 64.43 61.34 Dizygotic twins N 22 14 36 22 14 36 Median 0.71 0.60 0.67 50.68 53.15 52.00 25th perc. 0.57 0.57 0.57 42.90 48.79 43.17 75th perc. 0.90 0.76 0.82 55.73 57.70 55.83 p Value* 0.849 (NS) 0.462 (NS) 0.449 (NS) 0.807 (NS) 0.421 (NS) 0.634 (NS)

N, number of individuals; perc., percentile; Av. dist., average distance between the original and mirror faces of one twin; Coincid., the percentage of coincidence between the original and mirror faces of one twin (within 0.5 mm of tolerance); NS, not statistically signicant. *MannWhitney U test was performed.

especially comparisons between parents and children (14). An ongoing project aims at exploring this aspect of the problem, and the 12 |
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faces of approximately 1300 fathers of ALSPAC children are currently being laser scanned. Genome-wide associations will have a major

Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Table 7. Three-dimensional symmetry by facial thirds in monozygotic and dizygotic twins Upper facial third 25th Twins MZ males N 18 Parameter Av. dist. (mm) Coincid. (%) MZ females 20 Av. dist. (mm) Coincid. (%) MZ all 38 Av. dist. (mm) Coincid. (%) DZ males 22 Av. dist. (mm) Coincid. (%) DZ females 14 Av. dist. (mm) Coincid. (%) DZ all 36 Av. dist. (mm) Coincid. (%) Median 0.52 58.28 0.48 62.58 0.49 60.88 0.54 59.18 0.47 65.36 0.52 62.86 perc. 0.43 49.70 0.42 55.76 0.42 51.73 0.39 48.24 0.40 52.37 0.40 48.90 75th perc. 0.66 67.75 0.59 70.57 0.64 69.22 0.65 70.78 0.59 75.86 0.59 71.06 Median 0.57 53.36 0.55 56.19 0.56 54.16 0.56 55.53 0.68 47.02 0.60 54.11 Middle facial third 25th perc. 0.50 45.18 0.42 46.76 0.48 46.80 0.49 45.71 0.48 40.00 0.49 43.02 75th perc. 0.77 58.96 0.67 64.37 0.71 61.98 0.79 57.69 0.83 59.15 0.79 57.92 Median 1.00 29.71 0.79 38.87 0.94 31.04 1.30 21.30 0.82 32.63 1.20 26.07 Lower facial third 25th perc. 0.86 19.57 0.48 15.40 0.63 18.89 0.71 10.67 0.48 14.82 0.64 13.58 75th perc. 1.37 34.40 1.43 59.20 1.36 46.66 1.84 38.12 1.29 59.21 1.62 43.68 p Value <0.001 <0.001 0.012 0.003 <0.001 <0.001 <0.001 <0.001 0.026 0.007 <0.001 <0.001

N, number of individuals; perc., percentile; Av. dist., average distance between the original and mirror faces of one twin; Coincid., the percentage of coincidence between the original and mirror faces of one twin (within 0.5 mm of tolerance). Figures in bold indicate facial third which was signicantly different from the other two (MannWhitney U test was applied). NS, not statistically signicant. Kruskal-Wallis test was performed.

role in identifying genetic variants responsible for normal facial variations. It is believed that three-dimensional imaging will be of great help in the quest for further knowledge on genetic and environmental determinants of facial features.

3. Zygosity does not seem to inuence the amount of three-dimensional symmetry of facial soft tissues. Lower facial third is the most asymmetrical part of the face in both MZ and DZ twins.

Clinical relevance Conclusions

From this study on three-dimensional facial shape and symmetry of 15-year-old white British twins, the following conclusions can be drawn: 1. Landmark-based and surface-based threedimensional facial analyses can reveal within- and between-pair differences in facial soft tissue shapes of MZ and DZ twins. 2. Genetic factors play an important role in three-dimensional soft tissue shape and the relative contribution of genetic and environmental factors is not the same for the upper, middle and lower facial thirds. The twin method has been extensively used in orthodontics in the last few decades to investigate the relative contribution of genetic and environmental factors to the shape of the craniofacial complex. Three-dimensional imaging systems provide a possibility to obtain and analyse facial soft tissue morphology non-invasively, accurately and reliably. In this study, laser surface scanning was used to compare facial shape and symmetry of MZ and DZ twins. Suggested three-dimensional facial analyses can reveal differences in facial morphology, which has not been possible previously using two-dimensional data. This can support further research in craniofacial genetics.
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Djordjevic et al. 3D analysis of facial shape and symmetry in twins

Acknowledgements: We are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them and the whole ALSPAC study team, which includes interviewers, computer and laboratory technicians, clerical workers, research scien-

tists, volunteers, managers, receptionists and nurses. The UK Medical Research Council, the Wellcome Trust (Grant ref: 092731) and the University of Bristol provide core support for ALSPAC.

References
1. Emery AE, Mueller RF. Elements of Medical Genetics. Edinburgh: Churchill Livingstone; 1988. 2. http://www.genome.gov (accessed on 26th February 2012) 3. Freimer N, Sabatti C. The human phenome project. Nat Genet 2003;34:1521. 4. Peng J, Deng H, Cao CF, Ishikawa M. Craniofacial morphology in Chinese female twins: a semi-longitudinal cephalometric study. Eur J Orthod 2005;27:55661. 5. Carels C, Van Cauwenberghe N, Savoye I, Willems G, Loos R, Derom C et al. A quantitative genetic study of cephalometric variables in twins. Clin Orthod Res 2001;4:13040. 6. Savoye I, Loos R, Carels C, Derom C, Vlietinck R. A genetic study of anteroposterior and vertical facial proportions using model-tting. Angle Orthod 1998;68:46770. 7. Manfredi C, Martina R, Grossi GB, Giuliani M. Heritability of 39 orthodontic cephalometric parameters on MZ, DZ twins and MN paired singletons. Am J Orthod Dentofacial Orthop 1997;111:4451. 8. Lobb WK. Craniofacial morphology and occlusal variation in monozygotic and dizygotic twins. Angle Orthod 1987;57:21933. m A, McWilliam JS. A com9. Lundstro parison of vertical and horizontal variables with regard to heritability. Eur J Orthod 1987;9:1048. 10. Alkhudhairi TD, AlKode EA. Cephalometric craniofacial features in Saudi parents and their offspring. Angle Orthod 2010;80:101017. 11. Sherwood RJ, Duran DL, Demerath EW, Czerwinski SA, Siervogel RM, Towne B. Quantitative genetics of modern human cranial variation. J Hum Evol 2008;54:90914. 12. Baydas B, Erdem A, Yavuz I, Ceylan I. Heritability of facial proportions and soft-tissue prole characteristics in Turkish Anatolian siblings. Am J Orthod Dentofacial Orthop 2007;131:5049.

r IE, Karaman AI, Zekic 13. Gelgo E. The use of parental data to evaluate soft tissues in an Anatolian Turkish population according to Holdaway soft tissue norms. Am J Orthod Dentofacial Orthop 2006;129:330 e19. 14. Johannsdottir B, Thorarinsson F, Thordarson A, Magnusson TE. Heritability of craniofacial characteristics between parents and offspring estimated from lateral cephalograms. Am J Orthod Dentofacial Orthop 2005;127:2007. 15. Paternoster L, Zhurov AI, Toma AM, Kemp JP, St Pourcain B, Timpson NJ et al. Genome-wide association study of three-dimensional facial morphology identies a variant in PAX3 associated with nasion position. Am J Hum Genet 2012;90:478 85. 16. Kohn LAP. The role of genetics in craniofacial morphology and growth. Annu Rev Anthropol 1991;20:26178. 17. Kau CH, Richmond S. Three-Dimensional Imaging for Orthodontics and Maxillofacial Surgery. Ames, IA: Wiley Blackwell; 2010. 18. Kau CH, Richmond S, Incrapera A, English J, Xia JJ. Three-dimensional surface acquisition systems for the study of facial morphology and their application to maxillofacial surgery. Int J Med Robotics Comput Assist Surg 2007;3:97110. 19. Burke PH. Intrapair facial differences in twins. Acta Genet Med Gemellol 1989;38:3747. 20. Burke PH, Healy MJR. A serial study of normal facial asymmetry in monozygotic twins. Ann Hum Biol 1993;20:52734. 21. Naini FB, Moss JP. Three-dimensional assessment of the relative contribution of genetics and environment to various facial parameters with the twin method. Am J Orthod Dentofacial Orthop 2004;126:65565. 22. Moss JP. The use of three-dimensional imaging in orthodontics. Eur J Orthod 2006;28:41625.

23. Golding J, Pembrey M, Jones R, the Alspac Study Team. ALSPAC The Avon Longitudinal Study of Parents and Children. I. Study methodology. Paediatr Perinat Epidemiol 2001;15:7487. 24. Boyd A, Golding J, Macleod J, Lawlor DA, Fraser A, Henderson J et al. Cohort prole: the children of the 90sthe index offspring of the Avon Longitudinal Study of Parents and Children. Int J Epidemiol 16 Apr 2012; (epub ahead of print) doi: 10.1093/ije/dys064 25. Toma AM, Zhurov AI, Playle R, Marshall D, Rosin PL, Richmond S. The assessment of facial variation in 4747 British school children. Eur J Orthod 2012;34:65564. 26. Kau CH, Knox J, Zhurov AI, Richmond S. The validity and reliability of a portable 3-dimensional laser scanner for eld studies. In: Giuliani R, Galliani E, editors. 7th European Craniofacial Congress. Bologna: Monduzzi Editore International Proceedings Division; 2004. pp. 415. 27. Kau CH, Richmond S, Zhurov AI, Bouwman S, Scheer R. Feasibility of measuring 3D facial morphology in children. Orthod Craniofac Res 2005;7:17. 28. Kau CH, Zhurov AI, Knox J, Chestnutt I, Hartles FR, Playle R et al. Reliability of measuring facial morphology using a 3-dimensional laser scanning system. Am J Orthod Dentofacial Orthop 2005;128:42430. 29. Kau CH, Richmond S, Savio C, Mallorie C. Measuring adult facial morphology in three dimensions. Angle Orthod 2006;76:7738. 30. Kovacs L, Zimmermann A, Brockmann G, Baurecht H, SchwenzerZimmerer K, Papadopulos NA. Accuracy and precision of the threedimensional assessment of the facial surface using a 3-D laser scanner. IEEE Trans Med Imaging 2006;25: 74254.

14 |

Orthod Craniofac Res 2012

Djordjevic et al. 3D analysis of facial shape and symmetry in twins

31. Kusnoto B, Evans CA. Reliability of a 3D surface laser scanner for orthodontic applications. Am J Orthod Dentofacial Orthop 2002;122:3428. 32. Zhurov AI, Kau CH, Richmond S. Computer methods for measuring 3D facial morphology. In: Middleton J, Shrive N, Jones M, editors. Proceedings of the 6th International Symposium on Computer Methods in Biomechanics & Biomedical Engineering. Cardiff: First Numerics Ltd; 2005. (CD ROM, paper 151D). 33. Kau CH, Hartles FR, Knox J, Zhurov AI, Richmond S. Natural head posture for measuring three-dimensional soft tissue morphology. In: Middleton J, Shrive N, Jones M, editors. Proceedings of the 6th International Symposium on Computer Methods in Biomechanics & Biomedical Engineering. Cardiff: First Numerics Ltd; 2005. (CD ROM, paper 149D).

34. Kau CH, Hartles FR, Knox J, Zhurov AI, Richmond S. Measuring facial morphology in young subjects. In: Middleton J, Shrive N, Jones M, editors. Proceedings of the 6th International Symposium on Computer Methods in Biomechanics & Biomedical Engineering. Cardiff: First Numerics Ltd; 2005. (CD ROM, paper 150D). 35. Toma AM, Zhurov A, Playle R, Richmond S. A three-dimensional look for facial differences between males and females in a British-Caucasian sample aged 15 1/2 years old. Orthod Craniofac Res 2008;11:1805. 36. Farkas LG, editor. Anthropometry of the Head and Face. New York: Raven Press; 1994. 37. Bookstein FL. Morphometric Tools for Landmark Data. Cambridge: Cambridge University Press; 1991. 38. Zelditch ML, Swiderski DL, Sheets HD, Fink WL. Geometric Morpho-

39.

40.

41.

42.

metrics for Biologists: A Primer. New York: Elsevier academic press; 2004. Djordjevic J, Pirttiniemi P, Harila V, Heikkinen T, Toma AM, Zhurov AI et al. Three-dimensional longitudinal assessment of facial symmetry in adolescents. Eur J Orthod 2011; Feb 7 (epub ahead of print) doi: 10.1093/ ejo/cjr006. Djordjevic J, Toma AM, Zhurov AI, Richmond S. Three-dimensional quantication of facial symmetry in adolescents using laser surface scanning. Eur J Orthod 2011; Jul 27 (epub ahead of print) doi: 10.1093/ ejo/cjr091. Toma AM, Zhurov A, Playle R, Ong E, Richmond S. Reproducibility of facial soft tissue landmarks on 3D laser-scanned facial images. Orthod Craniofac Res 2009;12:3342. Huang GJ, Richmond S, Vig KWL. Evidence-Based Orthodontics. Ames, IA: Wiley-Blackwell; 2011.

Orthod Craniofac Res 2012

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