Three-dimensional analysis of nasolabial soft tissue changes after Le Fort I osteotomy: a systematic review of the literature

A systematic review was conducted to investigate the three-dimensional (3D) effect of Le Fort I osteotomy on the nasolabial soft tissues. The literature search was conducted using the MEDLINE (accessed via PubMed), Embase, and Cochrane electronic databases until January 2018. A total of 333 studies were identified (PubMed, n = 292; Embase, n = 41; Cochrane Library, n = 0). Seventeen met the inclusion criteria. The studies were essentially retrospective. The risk of bias was considered high in 15 studies, medium in one study, and low in one study. 3D soft tissue analysis was performed at least 6 months after surgery (mean 8.3 months). The main image acquisition technique reported was cone beam computed tomography (CBCT), associated or not with 3D photography. Approximately 50% of the studies performed two-jaw surgery, 25% performed maxillary surgery only, and the other 25% included heterogeneous intervention groups. The most reported nasolabial changes were anterior and lateral movements of the nasomaxillary soft tissues and upper lip, together with anterior and superior movement of the nasal tip. The alar cinch suture and V–Y closure technique seemed to have little effect in counteracting the undesirable postoperative nasolabial changes. CBCT superimposition presented a reliable 3D assessment for simultaneous measurement of skeletal and soft tissue changes.     

Effect of setback Le Fort I osteotomy on midfacial soft-tissue changes as evaluated by cone-beam computed tomography superimposition for cases of skeletal Class III malocclusion

This study employed the cone-beam computed tomography (CBCT) superimposition method to evaluate postoperative midfacial soft-tissue changes in cases of skeletal Class III malocclusion after double-jaw surgery with setback and vertical reduction Le Fort I osteotomy. A retrospective study was carried out on 15 patients who had undergone maxillary setback Le Fort I osteotomy and mandibular setback sagittal split ramus osteotomy with alar cinch suturing and V-Y soft-tissue closure. Three dimensional CBCT volume scans were recorded preoperatively (T0) and 6 months postoperatively (T1) to measure soft-tissue changes of the upper lip and midface. Post-surgery, soft-tissue landmarks in the cheek and paranasal areas had moved forward; the soft-tissue thickness at the A-point had markedly increased (P < 0.05); there was no significant change in the subnasale, and the midline of the soft-tissue of the upper-lip area had moved backward. The extent of the mean soft-tissue change at the labrale superius was greater than that at the other soft-tissue landmarks of the upper lip. The results suggest that maxillary setback movement of the maxilla by alar cinch suturing has a beneficial effect on paranasal soft-tissue and lip contours for patients with protrusive lip and acute nasolabial angle.     

Morphological changes in the pharyngeal airway of female skeletal class III patients following bimaxillary surgery: A cone beam computed tomography evaluation

Using cone beam computed tomography (CBCT), the present study compared three-dimensional (3D) changes in the pharyngeal airway and surrounding tissues in female skeletal class III patients treated with bimaxillary surgery. Twenty-nine female skeletal class III patients with both maxillary hypoplasia and a mandibular excess underwent bilateral sagittal split ramus osteotomy for mandibular setback combined with Le Fort I osteotomy for maxillary advancement. Volumetric measurements were performed using CBCT scans taken at 1 week presurgery and 6 months post-surgery. The oropharynx volumes and the cross-sectional area behind the soft palate decreased significantly. There was an insignificant change in the volume of the nasopharynx (P > 0.05). The hyoid bone moved downward and posteriorly after surgery. The morphology of the soft palate also changed dramatically, with an increase in the length and thickness. Negative correlations were found between the pharyngeal airway space and the position of the hyoid bone. The change in morphology of the soft palate was significantly correlated with the changes in hyoid bone position. These 3D results suggest that bimaxillary orthognathic surgery significantly changes the position of the hyoid bone and the soft palate together with a significant decrease in the pharyngeal airway space in the correction of skeletal class III malocclusion.     

Changes in soft tissue profile after mandibular setback surgery in Class III subjects

The aim of this study was to investigate changes in hard and soft tissue profile after mandibular setback surgery. Lateral cephalograms of 25 Class III subjects were assessed before and 1.5 ± 0.4 years after mandibular setback surgery. Paired t test, Pearson correlation test and linear regression analysis were used to evaluate the changes in soft tissue profile. Significant changes were found in skeletal (SNB ?3.6 ± 0.9°, ANB 3.7 ± 1.0°, overjet 5.0 ± 1.2 and overbite 2.5 ± 1.1 mm, P < 0.001), soft tissue (facial convexity 5.9 ± 1.6°, P < 0.001; labiomental fold 0.6 ± 0.6 mm, P < 0.001; upper and lower lip protrusion 0.5 ± 0.8 mm, P < 0.01; ?3.3 ± 1.2 mm, P < 0.001), and upper and lower lip lengths (0.9 ± 1.2 mm, P < 0.01; ?1.8 ± 2.1 mm, P < 0.001). Correlations were found between facial convexity and SNB and ANB angles and between upper lip length and SNB and ANB angles. The change in lower lip length was correlated with SNB, ANB, overjet and overbite. Lower lip retrusion was correlated with overjet and a significant correlation was found between the retrusion of lower incisor and lower lip. Mandibular setback surgery was effective in producing an orthognathic profile in adult Class III subjects with mandibular prognathism.     

Two-point nasomaxillary fixation of the Le Fort I osteotomy: assessment of stability at one year postoperative

The purpose was to assess maxillary position among patients undergoing Le Fort I maxillary advancement with internal fixation placed only at the nasomaxillary buttresses. This was a retrospective study of patients undergoing a Le Fort I osteotomy for maxillary advancement, with internal fixation placed only at the nasomaxillary buttresses. Demographic and cephalometric measures were recorded. The outcome of interest was the change in maxillary position between immediately postoperative (T1), 6 weeks postoperative (T2), and 1 year postoperative (T3). Fifty-eight patients were included as study subjects (32 male, 26 female; mean age 18.4 ± 1.8 years). Twenty-five subjects (43.1%) had a diagnosis of cleft lip and palate. Forty-three subjects (74.1%) had bimaxillary surgery, 16 (27.6%) had bone grafts, and 18 (31.0%) had segmental maxillary osteotomies. At T3, there were no subjects with non-union, malunion, malocclusion, or relapse requiring repeat surgery. Mean linear changes between T1 and T3 were ≤1 mm. Mean angular changes between T1 and T3 were <1°. There was no significant difference in stability in multi-segment maxillary osteotomies (P =  0.22) or with bone grafting (P =  0.31). In conclusion, anterior fixation alone in the Le Fort I osteotomy results in a stable maxillary position at 1 year postoperative.     

Three-dimensional soft tissue prediction in orthognathic surgery: a clinical comparison of Dolphin,ProPlan CMF,and probabilistic finite element modelling

Three-dimensional surgical planning is used widely in orthognathic surgery. Although numerous computer programs exist, the accuracy of soft tissue prediction remains uncertain. The purpose of this study was to compare the prediction accuracy of Dolphin, ProPlan CMF, and a probabilistic finite element method (PFEM). Seven patients (mean age 18 years; five female) who had undergone Le Fort I osteotomy with preoperative and 1-year postoperative cone beam computed tomography (CBCT) were included. The three programs were used for soft tissue prediction using planned and postoperative maxillary position, and these were compared to postoperative CBCT. Accurate predictions were obtained with each program, indicated by root mean square distances: RMS_Dolphin = 1.8 ± 0.8 mm, RMS_ProPlan = 1.2 ± 0.4 mm, and RMS_PFEM = 1.3 ± 0.4 mm. Dolphin utilizes a landmark-based algorithm allowing for patient-specific bone-to-soft tissue ratios, which works well for cephalometric radiographs but has limited three-dimensional accuracy, whilst ProPlan and PFEM provide better three-dimensional predictions with continuous displacements. Patient or population-specific material properties can be defined in PFEM, while no soft tissue parameters are adjustable in ProPlan. Important clinical considerations are the topological differences between predictions due to the three algorithms, the non-negligible influence of the mismatch between planned and postoperative maxillary position, and the learning curve associated with sophisticated programs like PFEM.     

Nasolabial soft tissue effects of segmented and non-segmented Le Fort I osteotomy using a modified alar cinch technique—a cone beam computed tomography evaluation

The aim of this study was to verify soft tissues changes and the effect of a minimally invasive surgical technique in the nasolabial region after segmented and non-segmented Le Fort I osteotomy, using cone beam computed tomography (CBCT) evaluation of three-dimensional (3D) volume surfaces. Two groups were evaluated: group 1, bimaxillary surgery with maxillary segmentation (n = 40); group 2, bimaxillary surgery without maxillary segmentation (n = 40). In both groups, a specific alar cinching technique was used to control nasal base broadening. CBCT evaluation was performed at three different treatment time points: T0, 1 month before surgery; T1, 1 month after surgery; T2, 1 year after surgery. The results showed statistically significant differences in the nasolabial area (P < 0.001). For group 1, the mean change in alar base width (Al_inf–Al_inf) was 1.31 ± 1.40 mm at T1 and 0.93 ± 1.77 mm at T2; for group 2 these values were 1.12 ± 2.01 mm at T1 and 0.54 ± 1.54 mm at T2. For group 1, the mean changes in inter-alar width (Al–Al) were 1.68 ± 1.46 mm at T1 and 1.49 ± 1.33 mm at T2; for group 2, they were 2.22 ± 1.93 mm at T1 and 1.34 ± 1.79 mm at T2. The alar cinch technique proposed here appears to be effective in controlling nasolabial soft tissue widening.     

Le Fort I osteotomies using Bio-Oss® Collagen to promote bony union: a prospective clinical split-mouth study

The purpose of this study was to evaluate whether a bone substitute can be used to promote bony union in patients undergoing maxillary advancement after Le Fort l osteotomy. Nine patients were treated bilaterally with Le Fort I osteotomies and maxillary advancements of 5 mm or less. In each patient, one gap was grafted with the bone substitute Bio-Oss^® Collagen (BOC). The contralateral site was left empty and served as control. After 6 months there were still empty gaps in the control sites of three patients, while in the grafted sites all gaps were completely filled with bone. The histomorphometric analysis performed with biopsies from the region of the original gap showed a similar amount of new bone in both groups, however, in the test group the mean overall amount of the mineralized fraction was higher compared to the control group (test site 65.0 ± 6.2%, control site 38.9 ± 32.6%). The bone substitute seemed to be a suitable material to promote bony union in Le Fort I osteotomies. Further studies are needed to analyse whether this technique is efficient in preventing relapse and promoting bony union in larger advancements.     

Validation of a novel semi-automated method for three-dimensional surface rendering of condyles using cone beam computed tomography data

Morphological changes of the condyles are often observed following orthognathic surgery. In addition to clinical assessment, radiographic evaluation of the condyles is required to distinguish the physiological condylar remodelling from pathological condylar resorption. The low contrast resolution and distortion of greyscale values in cone beam computed tomography (CBCT) scans have impeded an accurate three-dimensional (3D) rendering of the condyles. The current study proposes a novel semi-automated method for 3D rendering of condyles using CBCT datasets, and provides a clinical validation of this method. Ten patients were scanned using a standard CBCT scanning protocol. After defining the volume of interest, a greyscale cut-off value was selected to allow an automatic reconstruction of the condylar outline. The condylar contour was further enhanced manually by two independent observers to correct for the under- and over-contoured voxels. Volumetric measurements and surface distance maps of the condyles were computed. The mean within-observer and between-observer differences in condylar volume were 8.62 mm³ and 6.13 mm³, respectively. The mean discrepancy between intra- and inter-observer distance maps of the condylar surface was 0.22 mm and 0.13 mm, respectively. This novel method provides a reproducible tool for the 3D rendering of condyles, allowing longitudinal follow-up and quantitative analysis of condylar changes following orthognathic surgery.     

Effects of maxillary advancement and impaction on nasal airway function

The effects of Le Fort I osteotomy on the nasal airway are controversial. This study aimed to evaluate nasal airway changes after Le Fort I. 25 patients underwent conventional Le Fort I osteotomy and were separated into three groups depending on the type of surgery they underwent. 11 patients needed maxillary impaction, 9 underwent maxillary advancement, and 5 had both maxillary impaction and advancement. Rhinological examinations, anterior rhinomanometry and acoustic rhinometry were carried out 1 week before surgery and 3 months after that. Wilcoxon and χ² tests were used for data analysis. The samples included 19 females and 6 males with a mean age of 22.4 ± 3.32 years. Rhinomanometric assessment showed that total nasal airflow was increased from 406 ± 202 ml/s to 543 ± 268 ml/s in all three groups. Significant decrease in nasal airway resistance was seen in all three groups. Acoustic rhinometry revealed a significant decrease in total nasal volume but an increase in the cross-sectional areas of isthmus nasi (IN) and inferior concha. The rhinomanometric measurements showed improvements in the total nasal airflow after Le Fort I osteotomy with alar base cinch suture in cases where the impaction was not higher than 5.5 mm.     

Systematic review of changes in maxillary incisor exposure and upper lip position with Le Fort I type osteotomies with or without cinch sutures and/or VY closures

The aim was to systematically review the maxillary incisor exposure and upper lip position changes with Le Fort I type osteotomies for advancement ± impaction with rigid internal fixation, taking into account the use of cinch sutures and VY closures. Electronic databases (Cochrane Library, Medline, Embase, and Web of Science) were searched using medical subject headings (MeSH), key words, truncations, and Boolean operators. Hand searching was also undertaken. Of 979 articles identified, 15 were included (11 retrospective, two prospective, and two unspecified). Relevant study details and outcomes were recorded on a spreadsheet, along with an assessment of their quality. In total, these studies assessed 419 patients (266 female, 118 male) with a mean age of 26.4 years (range 14–57 years). Soft tissue changes were assessed on lateral cephalometric radiographs. The mean maxillary hard tissue advancement and impaction ranged between 0.94 and 8.77 mm and −0.56 and 4.2 mm, respectively. The ranges of ratios demonstrated that from pronasale (0.24–0.35) to labrale superius (0.36–1.43), the soft tissues followed the underlying horizontal hard tissue movement increasingly more closely. Alar base cinch sutures and VY closures tended to increase these ratios. The soft tissue response was more variable vertically. None of the studies reported on maxillary incisor exposure change. More good quality prospective studies are needed.     

Validity of three-dimensional computed tomography measurements for Le Fort I osteotomy

The purpose of this study was to test the precision and accuracy of three-dimensional (3D) linear measurements for Le Fort I osteotomy, obtained from multi-slice computed tomography (MSCT) and cone beam computed tomography (CBCT) scans. The study population consisted of 11 dried skulls submitted to 64-row MSCT and CBCT scans. Three-dimensional reconstructed images (3D-CT) were generated, and linear measurements (n = 11) based on anatomical structures and landmarks of interest for Le Fort I osteotomy were performed independently by two oral and maxillofacial radiologists, twice each, using Vitrea software; this allows true 3D measurement on 3D-CT images. The results demonstrated no statistically significant differences between the inter-examiner and intra-examiner analyses, and physical and true 3D linear measurements using MSCT and CBCT images. Regarding examiner accuracy, no statistically significant differences were found for the comparisons among the physical and the MSCT and the CBCT linear measurements by either examiner. For examiners 1 and 2, the analysis intra-examiner correlation coefficient ranged from 0.87 to 0.96 and 0.82 to 0.98, respectively, using MSCT, and from 0.84 to 0.98 and 0.80 to 0.98, respectively, using CBCT, indicating almost perfect agreement for all analyses performed. 3D linear measurements obtained from MSCT and CBCT images were considered precise and accurate for Le Fort I osteotomy and thus accurate and helpful for Le Fort I osteotomy planning.     

Effect of remifentanil on the hemodynamic responses and recovery profile of patients undergoing single jaw orthognathic surgery

The aim of this study was to compare fentanyl-based versus remifentanil-based anesthesia with regards to the intraoperative hemodynamic stress response and recovery profiles in patients undergoing Le Fort I osteotomy. Seventeen patients were randomly divided into two groups: patients in the F-group received 2 μg/kg fentanyl intravenously followed by an infusion of 0.03–0.06 μg/kg/min, while patients in the R-group received a 0.5 μg/kg bolus of remifentanil followed by an infusion of 0.0625–0.250 μg/kg/min. Mean arterial pressure and heart rate were recorded at the following points: before anesthetic induction, at endotracheal intubation, 5 min after intubation, at incision, just before the osteotomy, during the osteotomy, during the maxillary fracturing, at suturing, at extubation, 5 min after extubation, and then 15 and 30 min postoperatively. Heart rate and mean arterial pressure were significantly lower in the R-group in comparison to the F-group from t₁ to t₉ (P < 0.05). All measured recovery times were significantly shorter in the R-group (P < 0.05). The incidence of postoperative side effects was comparable between groups. Remifentanil-based anesthesia is an appropriate alternative to fentanyl during Le Fort I orthognathic surgery; it promotes hemodynamic stability, blunts the stress response to noxious stimuli, and provides a better recovery profile.     

Evaluation of soft tissue prediction accuracy for orthognathic surgery with skeletal class III malocclusion using maxillofacial regional aesthetic units

Objectives

This study aimed to evaluate the soft tissue prediction accuracy of patients undergoing orthognathic surgery to correct skeletal class III malocclusion using maxillofacial regional aesthetic units.

Materials and methods

Pre- and postoperative cone-beam computed tomography (CBCT) and 3D facial scans were taken for 58 patients who had undergone orthognathic surgery. The preoperative 3D facial scan was integrated with the preoperative CBCT using ProPlan CMF software. The software simulated the surgery and generated postoperative soft tissue prediction. The simulated 3D facial scan was then compared with the actual 3D facial scan obtained at least 6 months after the surgery by the maxillofacial regional aesthetic units and the facial soft tissue landmark points.

Results

The anatomical regions of the upper lip, lower lip, chin, right external buccal and left external buccal prediction were above 2.0 mm. As for the soft tissue landmarks, at chl, chr, ls, stm and li, the position of predicted scan was higher than that of the actual postoperative scan.

Conclusions

The accuracy of 3D soft tissue predictions using ProPlan CMF software in Skeletal III patients was clinically satisfactory according to maxillofacial regional aesthetic units combined with facial soft tissue landmark points. However, the accuracy of prediction still needed improvement in some areas.

Clinical relevance

The accuracy of soft tissue prediction can be analyzed more clearly through maxillofacial regional aesthetic units so that clinicians have a deeper understanding of the use of the software to predict soft tissue change after orthognathic surgery.

     

Evaluation of neurosensory alterations via clinical neurosensory tests following anterior maxillary osteotomy (Bell technique)

Neurosensory deficits are the most common complication following orthognathic surgery. Le Fort I and sagittal split ramus osteotomies have been widely studied but there is a lack of data about the neurosensory alterations resulting from anterior maxillary osteotomy (AMO). This paper evaluates the neurosensory alterations in cutaneous regions including lower eyelid, cheek, nose, upper lip and vestibular and palatal mucosal areas using simple clinical tests following AMO performed with Bell's incision so patients can be properly informed about the extent of sensory loss and its rate of recovery following AMO. Twenty-four sides of 12 patients (eight females; four males) with a mean age of 14.20 ± 1.86 years (range 12–17 years) were examined. Pin prick sensation, light touch sensation, static and dynamic two-point discrimination tests were used. Following AMO, vestibular mucosa, upper lip, nose and cheek were the most commonly affected sites. No alterations were detected in lower eyelid and palatal mucosa. The neurosensory deficits in cheek, nose and upper lip resolved 10 days after surgery. The vestibular mucosa showed normal sensation on day 30. In conclusion, following AMO, neurosensory alterations can occur, but it will resolve spontaneously in 30 days.     

Evaluation of two-dimensional lateral cephalogram and three-dimensional cone beam computed tomography superimpositions: a comparative study

Superimposition of radiographic imaging is used to evaluate patient growth and the effects of surgical and/or orthodontic treatment. The purpose of this study was to compare the outcomes of superimposition between two-dimensional (2D) and three-dimensional (3D) superimpositions. 2D lateral cephalograms were generated from the initial and final cone beam computed tomography scans (CBCT) of 18 patients and superimposed. Both 3D CBCT and 2D CBCT generated lateral cephalograms were oriented to the Frankfort horizontal plane and superimposed according to the American Board of Orthodontics recommendations. Changes in landmark position were quantified from the resulting superimposition outcomes via linear measurements made with Dolphin software. Differences between the two methods were analyzed using paired t-tests. Measurements were repeated twice for 10 randomly selected scans to assess reliability by intra-class correlation coefficient (ICC) analysis. Intra-examiner reliability was high for all measurements (ICC > 0.84). Agreement between 2D and 3D superimposition outcomes, as measured by P-values, was low for ANS (P = 0.026), B-point (P < 0.001), ST Upper lip (P = 0.019), U1 tip (P = 0.010), and U1 apex (P = 0.026). 2D measurements were significantly higher than 3D measurements for ANS, B-point, ST Upper lip, U1 tip, and U1 apex. Findings indicated that both methods of superimposition (2D and 3D) are highly reliable. Statistical differences between 2D and 3D superimposition outcomes were below the threshold of clinical significance.     

A cone-beam CT based technique to augment the 3D virtual skull model with a detailed dental surface

Cone-beam computed tomography (CBCT) is used for maxillofacial imaging. 3D virtual planning of orthognathic and facial orthomorphic surgery requires detailed visualisation of the interocclusal relationship. This study aimed to introduce and evaluate the use of a double CBCT scan procedure with a modified wax bite wafer to augment the 3D virtual skull model with a detailed dental surface. The impressions of the dental arches and the wax bite wafer were scanned for ten patient separately using a high resolution standardized CBCT scanning protocol. Surface-based rigid registration using ICP (iterative closest points) was used to fit the virtual models on the wax bite wafer. Automatic rigid point-based registration of the wax bite wafer on the patient scan was performed to implement the digital virtual dental arches into the patient's skull model. Probability error histograms showed errors of ≤0.22 mm (25% percentile), ≤0.44 mm (50% percentile) and ≤1.09 mm (90% percentile) for ICP surface matching. The mean registration error for automatic point-based rigid registration was 0.18 ± 0.10 mm (range 0.13–0.26 mm). The results show the potential for a double CBCT scan procedure with a modified wax bite wafer to set-up a 3D virtual augmented model of the skull with detailed dental surface.     

Maxillary sinus recovery and nasal ventilation after Le Fort I osteotomy: a prospective clinical,endoscopic, functional and radiographic evaluation

The condition of the maxillary sinus is not routinely assessed before a Le Fort I osteotomy. Performing this procedure in an infected sinus might account for a considerable proportion of the complications, such as excessive bleeding and sinusitis. The aim of this study was to evaluate the maxillary sinus and nasal ventilation after Le Fort I osteotomy. Twenty patients were evaluated before and 2 months after surgery using validated questionnaires for sinonasal complaints (RSOM-31 and VAS score), nasal endoscopy, peak nasal inspiratory flow (PNIF), and a computed tomography (CT) scan. There were no differences in complaints before and 2 months after surgery (P > 0.24). Also, the PNIF did not change significantly (P = 0.10). On CT evaluation before surgery, a previously unnoted sinusitis was diagnosed in two patients. Postoperatively, a thickened sinus mucosa was present in all patients near the osteotomy line, the osteosyntheses, and around sequesters. This report describes maxillary sinus evaluation after Le Fort I osteotomy in a more comprehensive way by using CT. The Le Fort I procedure did not influence already existing physical or mental complaints, and nasal ventilation was not negatively affected. However, evaluation of sinonasal pathology should be emphasized in the preoperative work-up.     

Variables associated with stability after Le Fort I osteotomy for skeletal class III malocclusion

The purpose of this study was to assess skeletal stability and predictors of relapse in patients undergoing an isolated Le Fort I osteotomy. A retrospective cohort study of 92 subjects undergoing Le Fort I osteotomy for Class III malocclusion was implemented. Predictor variables were demographic and perioperative factors. The primary outcome variable was postoperative skeletal position with relapse defined as >2 mm sagittal and/or vertical change at A-point on serial lateral cephalograms at immediate postoperative, 1 year, and latest follow-up time points. Mean advancement at A-point was 6.28 ± 2.63 mm and mean lengthening was 0.92 ± 1.76 mm. Eight subjects (8.70%) had relapse (>2 mm) in the sagittal plane, and two subjects (2.17%) in the vertical plane. No subjects required reoperation for relapse as overbite and overjet remained in an acceptable range due to dental compensation. In regression analysis, magnitude of maxillary advancement was an independent predictor of relapse in the sagittal plane (P = 0.008). There were no significant predictors of relapse in the vertical plane. This study suggests that isolated Le Fort I osteotomy for correction of skeletal Class III malocclusion is a stable procedure and that greater advancement is an independent risk factor for sagittal relapse.     

Variation between natural head orientation and Frankfort horizontal planes in orthognathic surgery patients: 187 consecutive cases

The purpose of this study was to assess the relationship between the Frankfort horizontal (FH) and natural head orientation (NHO), their correlation between patients’ malocclusion, and the impact of counterclockwise rotation (CCW) on the FH-NHO angle variation after orthognathic surgery. An evaluation of 187 consecutive patients was performed at the Maxillofacial Institute (Teknon Medical Center, Barcelona). FH-NHO° was measured pre- and postoperatively at 1 and 12 months, after three-dimensional (3D) superimposition using a software (Dolphin®). Patients were classified as follows: 3.2%, 48.7% and 48.1%, class I, II and III, respectively. Baseline FH-NHO° was significantly positive for patients with dentofacial deformities (2.73° ± 4.19 (2.12–3.33°, P < 0.001). The impact of orthognathic surgery in FH-NHO° was greater in class II when compared with class III patients, with a variation of 2.04° ± 4.79 (P < 0.001) and −1.20° ± 3.03 (P < 0.001), respectively. FH-NHO° increased when CCW rotational movements were performed (P = 0.006). The results of this study suggest that pre- and postoperative NHO differs from FH in orthognathic patients. The angle between FH and NHO is significantly larger in class III than in class II patients at baseline, which converges after orthognathic surgery when CCW rotation is performed. Therefore, NHO should be used as the real horizontal plane when planning for orthognathic surgery.