Identifying Three-Dimensional Facial Fluctuating Asymmetry in Normal Pediatric Individuals: A Panel Assessment Outcome Study of Clinicians and Observers

Comparison of Different 3D Surface Registration-Based Methods to Assess Facial Asymmetry

BACKGROUND/OBJECTIVES

Facial asymmetry is gaining an increasing diagnostic interest in many clinical contexts. Several three-dimensional surface-based methods have been proposed for its assessment; however, they might provide non-equivalent data. Since there is a lack of comparative studies in these terms, this study aims to compare three methods for assessing the asymmetry of the face and facial thirds, thus addressing whether the potential differences can be considered clinically acceptable or not.

METHODS

Two 'maxillofacial' methods based on the trigeminal nerve distribution and one 'orthodontic' method based on reference horizontal planes were used to identify the facial thirds on 3D facial models of 80 Italian healthy adults to calculate the asymmetry of the face, and the upper, middle, and lower thirds of the face differently selected by each method. As a measure of asymmetry, the Root Mean Square value was calculated through a mirroring surface-based registration. Intra- and inter-operator reliability was verified for each method. Differences and interchangeability between the methods were tested, respectively, by two-way repeated measures ANOVA (Analysis of Variance) and Bland-Altman and Similarity Percentage model analysis. Additionally, the time required to perform each method was assessed.

RESULTS

All methods demonstrated excellent intra- and inter-operator reliability. While the ANOVA analysis found significant differences (p < 0.001) for the majority of facial Regions of Interest between each method, the Bland-Altman analysis revealed that the differences were clinically acceptable (<0.50 mm) for all facial regions between the trigeminal methods, and for the face and the upper third of the face between the orthodontic method, which was revealed to be faster, and the trigeminal ones. The additional similarity percentage model provided visual support for the complete interchangeability of the two trigeminal methods, as evidenced by the lower Coefficient of Variation value.

CONCLUSIONS

There is no best method for assessing facial asymmetry that applies to all types of clinical settings, as we have shown that different methods may not be completely interchangeable. However, we suggest that the methods based on the trigeminal subdivision can be used interchangeably in contexts where the morpho-functional analysis of maxillofacial regions with different embryological origins is considered. Thus, the clinical setting imposes the choice of one method over another and, as we have pointed out, the consequent comparison of data with those obtained with methods whose interchangeability has been demonstrated.

Interpersonal impressions of cleft and non-cleft adolescents: A panel assessment study of peers, laypersons, and clinicians using 3dMD images

BACKGROUND

Patients with cleft lip and palate anomalies suffer from associated negative psychosocial effects despite undergoing reconstructive surgeries. Discrimination from others may be a contributing factor. We aim to understand whether people react differently to cleft and non-cleft subjects in questions regarding aesthetic appraisal and interpersonal impressions, as well as whether diverging opinions exist between people of different backgrounds.

MATERIALS AND METHODS

Using the 3dMD system, three-dimensional craniofacial images of cleft (n = 20) and non-cleft (n = 5) pediatric individuals were obtained and used to create a Likert scale-based questionnaire. Participants from three different backgrounds, including adolescent peers, adult laypersons, and plastic surgeons, were recruited to complete the assessment. The resulting data were transferred to a bar graph and analyzed with the item response theory-graded response model to estimate the latent traits and capability of each subject.

RESULTS

Non-cleft images obtained more positive responses than cleft images in questions of both aesthetic appraisal and interpersonal impressions. However, some of the cleft images were rated similarly, or even superior, to non-cleft images in questions regarding interpersonal impressions. Surgeons showed the greatest latent capability in differentiating between cleft and non-cleft images, followed by adult laypersons, and then adolescent peers.

CONCLUSIONS

Despite cleft patients experiencing drastic improvements in appearance post-repair, all subject groups responded differently to questions concerning aesthetic and social impressions of pediatric cleft and non-cleft images. Plastic surgeons were more critical than others. These findings may offer further insight to clinicians, educators, and caregivers into the social challenges faced by cleft individuals.

Perceptions of mandibular asymmetry among orthodontists, oral and maxillofacial surgeons, and laypersons

Background

Facial asymmetry is one reason orthodontic patients seek treatment. This study assessed the effect of mandibular asymmetry on facial esthetics and treatment needs perceived by laypersons, orthodontists, and maxillofacial surgeons.

Materials and Method

In this descriptive cross-sectional study, the frontal image of a model was captured and symmetrized from the facial midline using Adobe Photoshop software. The mandible was rotated 0°-8° with 1° intervals. Images were presented to 41 laypersons, 39 orthodontists, and 29 surgeons using an online questionnaire. The observers rated each image's esthetics with a 0-100 Visual Analog Scale and determined their treatment need by choosing one of the following three choices: No need for treatment, needs treatment, acceptable, but better to be treated. Analysis of variance for repeated measurements model. The regression method, Kruskal-Wallis analysis, was used for statistical analysis and the level of significance was set as P < 0.05.

Results

The images with 0° and 1° rotation received the highest esthetic rates among all three groups, while the images with 8° rotation were the least attractive ones. Furthermore, the image esthetic ratings significantly affected their treatment need. Mandibular asymmetry diagnosis threshold was 1° for orthodontists, and 3° for both laypersons and surgeons. The treatment need threshold was 5°, 6°, and 7° for surgeons, orthodontists, and laypersons, respectively.

Conclusion

The esthetics of images decreased when mandibular asymmetry increased. Treatment need was also related to increased asymmetry. Orthodontists were the most sensitive group in diagnosis, while surgeons were the most sensitive ones when it came to treatment.

Subjective evaluation of facial asymmetry with three-dimensional simulated images among the orthodontists and laypersons: a cross-sectional study

OBJECTIVES

We used three-dimensional (3D) virtual images to undertake a subjective evaluation of how different factors affect the perception of facial asymmetry among orthodontists and laypersons with the aim of providing a quantitative reference for clinics.

MATERIALS AND METHODS

A 3D virtual symmetrical facial image was acquired using FaceGen Modeller software. The left chin, mandible, lip and cheek of the virtual face were simulated in the horizontal (interior/exterior), vertical (up/down), or sagittal (forward or backward) direction in 3, 5, and 7 mm respectively with Maya software to increase asymmetry for the further subjective evaluation. A pilot study was performed among ten volunteers and 30 subjects of each group were expected to be included based on 80% sensitivity in this study. The sample size was increased by 60% to exclude incomplete and unqualified questionnaires. Eventually, a total of 48 orthodontists and 40 laypersons evaluated these images with a 10-point visual analog scale (VAS). The images were presented in random order. Each image would stop for 30 s for observers with a two-second interval between images. Asymmetry ratings and recognition accuracy for asymmetric virtual faces were analyzed to explore how different factors affect the subjective evaluation of facial asymmetry. Multivariate linear regression and multivariate logistic regression models were used for statistical data analysis.

RESULTS

Orthodontists were found to be more critical of asymmetry than laypersons. Our results showed that observers progressively decreased ratings by 1.219 on the VAS scale and increased recognition rates by 2.301-fold as the degree of asymmetry increased by 2 mm; asymmetry in the sagittal direction was the least noticeable compared with the horizontal and vertical directions; and chin asymmetry turned out to be the most sensitive part among the four parts we simulated. Mandible asymmetry was easily confused with cheek asymmetry in the horizontal direction.

CONCLUSIONS

The degree, types and parts of asymmetry can affect ratings for facial deformity as well as the accuracy rate of identifying the asymmetrical part. Although orthodontists have higher accuracy in diagnosing asymmetrical faces than laypersons, they fail to correctly distinguish some specific asymmetrical areas.

Measuring asymmetry in facial morphea via 3-dimensional stereophotogrammetry

BACKGROUND

Objectively determining tissue loss in craniofacial morphea is challenging. However, 3-dimensional (3D) stereophotogrammetry is a noninvasive modality that may be a useful adjunct.

OBJECTIVE

To prospectively evaluate 3D stereophotogrammetry in the assessment of craniofacial linear morphea.

METHODS

Participants underwent clinical, quality-of-life, and 3D-stereophotogrammetry assessments. Traditional photographs and 3D-stereophotogrammetry images were rated as mild, moderate, or severe by 2 experts and 2 nonexperts. In addition, interrater and intrarater reliability (on delayed rescoring) were calculated.

RESULTS

Of 23 patients with craniofacial morphea, 3D stereophotogrammetry detected pathologic asymmetry in 14 (20.6%) patients. Providers rated patients as more severely affected when using 3D stereophotogrammetry versus when using traditional photographs (19% severe on 3D stereophotogrammetry vs 0% severe on traditional photographs, P = .004). Qualitative ratings of both traditional and 3D images showed high inter- and intrarater reliability between experts and nonexperts alike. Physicians' Global Assessment of Damage scores correlated with mouth asymmetry (P = .0021), cheek asymmetry (P = .04), and 3D-stereophotogrammetry ratings (median, mild: 27.5 vs moderate: 46.5 vs severe: 64, P = .0152). Lower face asymmetry correlated with worse quality-of-life scores (P = .013).

LIMITATIONS

Small sample size and cross-sectional design.

CONCLUSION

3D stereophotogrammetry can reliably detect and quantify asymmetry in craniofacial morphea with greater sensitivity than that observed with traditional assessment alone. 3D stereophotogrammetry may be a useful adjunct to clinical examination.

Longitudinal composite 3D faces and facial growth trends in children 6-11 years of age using 3D cephalometric surface imaging

BACKGROUND

Normative craniofacial anthropometry provides clinically important reference values used in the treatment of craniofacial conditions. Few objective datasets of normative data exist for children.

AIM

To establish normative data regarding craniofacial morphology changes with growth in children.

SUBJECTS AND METHODS

3D surface images of the same group of healthy children aged 6 - 11 years old recruited from a Dallas school were taken annually between the years 2015 - 2020. Composite 3D cephalometric faces were created for boys and girls of each age. General and craniofacial anthropometric measurements were compared.

RESULTS

Seven hundred ninety one individual stereophotogrammetric acquisitions were used (400 boys, 391 girls) taken from 180 children. Linear facial, orbital, nasal, and oral anthropometric measurements revealed a consistent increase in magnitude with age. Composite 3D face comparisons revealed prominent vertical and anteroposterior growth trends in the lower and upper facial regions.

CONCLUSION

This study presents a longitudinal 3D control dataset of the same group of children over a 6-year period that can serve as reference norms for facial growth values and trends in children aged 6-11 years. The composite 3D normative faces are available for clinical and research purposes upon request, which may be interrogated and measured according to user need and preference.

Sleep, Distressed Appearance, and Quality of Life Relate to Satisfaction with Orthognathic Surgery

BACKGROUND

In this study, we aimed to identify factors correlating with satisfaction with orthognathic surgery in order to improve its outcome.

METHODS

We recruited 77 participants who had received orthognathic surgery and 32 age- and gender-matched normal-controls. Questionnaires that included devised questions for family support, Big Five Inventory, Derriford Appearance Score, Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, 36-Item Short-Form Health Survey, and a visual analogy scale for satisfaction, were completed before and one month and nine months after the surgery. The statistical analysis methods included descriptive statistics, t-test, and Pearson correlation.

RESULTS

All participants received the preoperative and one-month follow-up, while 28 also completed the nine-month follow-up. Satisfaction was not significantly related to demographic data, but long-term satisfaction was related to an extraverted personality. The preoperative and postoperative results of the Derriford Appearance Scale were related to short-term and long-term satisfaction. Furthermore, both the preoperative and one-month postoperative Pittsburgh Sleep Quality Index findings were significantly related to short-term satisfaction. The postoperative 36-Item Short-Form Health Survey was significantly related to short-term and long-term satisfaction.

CONCLUSIONS

Not only subjective distress and dysfunction of appearance but also sleep problems and quality of life were correlated to satisfaction with orthognathic surgery. In the future, relevant interventions can be developed to further improve patient's satisfaction and their physical and mental health.

Assessment of the Orbital and Auricular Asymmetry in Italian and Sudanese Children: A Three-Dimensional Study

The evaluation of the symmetry of orbital and ear soft tissues is important for aesthetic and reconstructive surgery. However, little information is available for these facial regions, especially in children. We analyzed the orbital and auricular symmetry in 418 Italian and 206 Sudanese subadult males divided into three age groups (8–11, 12–15, and 16–19 years old). Orbital and auricular height and width were measured for calculating fluctuating and directional asymmetry indices. Differences in asymmetry indices according to ethnicity and age group were assessed through the two-way ANOVA test (p < 0.01), while differences in the prevalence of right or left asymmetry according to ethnicity were assessed through the chi-square test. On average, directional asymmetry indices ranged from −2.1% to 1.1%, while fluctuating asymmetry indices ranged between 2.9% and 5.4%, corresponding to a small effect size and to 1.06–2.34 mm actual dimensions. Sudanese subjects showed a greater asymmetry for all the indices except for the fluctuating asymmetry of orbital height (p < 0.01). The directional asymmetry of auricular width increased with age. A prevalent right-side asymmetry was found for all the orbital indices (p < 0.001) in both populations, although significantly more prevalent in Sudanese individuals (over 83% for both measures), while auricular measures showed a prevalent left asymmetry exclusively in the Sudanese but with lower percentages. Aside from the limited effect size, the results proved the ethnic variability of asymmetry of orbital and auricle regions in children and suggest the need to collect more population data.

Short-term and Long-term Psychological Impact and Quality of Life of Patients Undergoing Orthognathic Surgery

Background

Orthognathic Surgery (OGS) is a surgery for patients with dento-facial deformity but not all patients are satisfied with its outcome. The purpose of this study is to find out the short-term and long-term psychological impact and quality-of-life of OGS.

Methods

77 participants receiving OGS and 32 age and gender-matched controls were enrolled. The data of questionnaires were collected before OGS, one month and 9 months after OGS, including short form of the Derriford-Appearance-Scale (DAS-24), Big-Five-Inventory (BFI), Hospital-Anxiety-and-Depression-Scale (HADS), Pittsburgh-sleep-quality-index (PSQI), and 36-Item Short-Form-Health-Survey (SF-36). Variables were presented as mean ± standard deviation or frequency. Paired t-test, ANOVA and MANOVA were used to evaluate the pre-and post-surgery data.

Results

Short-term and long-term satisfaction of OGS was high. Before OGS, BFI showed the extraversion had significant difference between the male and female OGS subgroups. Several domains of DAS-24 were significantly different between the OGS and the control groups. Both groups had no significant difference in PSQI, HADS and SF-36, except sleep-efficiency. After OGS, many domains of DAS-24 were significantly improved and the improvement persisted to 9 months later. Sleep-latency, physical-function, role-limitations-due-to-physical-health and social-functioning exacerbated after OGS. Sleep-latency, physical-function, and social-functioning were improved 9 months after OGS, but sleep-efficiency and role-limitations-due-to-physical-health were still significantly worse than controls.

Conclusion

People received OGS for unfavorable appearance and the surgery could decrease their distress of appearance and impact to their daily living. Through long-term assessment, we should pay attention to sleep problems and role-limitations-due-to-physical-health after OGS.

The Perception of the Severity of Facial Asymmetry among Laypersons, General Practitioners, Orthodontists, and Maxillofacial Surgeons

STATEMENT OF THE PROBLEM

The degree of asymmetry perception of dental and medical practitioners is influenced by several factors. The perceived asymmetry affect the treatment plan design.

PURPOSE

The aim of the present study was to investigate the consistency of facial asymmetry and identify the amounts of transverse asymmetry that can be regarded as normal and might need correction.

MATERIALS AND METHOD

In this cross-sectional descriptive study, three-dimensional (3D) images of a man and a women volunteer were obtained. Then transverse changes were applied by ZBrush software so that for each volunteer, seven 3D images of their face with varying degrees of facial transverse asymmetry were created. Then, the images were displayed to four groups of observers including layperson, general dentists, orthodontists, and maxillofacial surgeons. Finally, the consistency of the perception of these four groups of observers with the different degrees of facial asymmetry was compared.

RESULTS

Fourteen photographic samples were evaluated and ranked by 80 observers in four groups. The consistency of the perception of the facial transverse asymmetry was equal to 33%, which indicated a lack of consistency.

CONCLUSION

According to the findings of this study, there was no consistency between the groups. The perception of dental professionals and ordinary people regarding the severity of transverse facial asymmetry seems to be inconsistent.

Ideal Nasal Radix Position in Fluctuating Facial Asymmetry

BACKGROUND

Augmentation rhinoplasty had become increasingly popular among Asians. Failure to recognize nasal deviation before surgery may engender unsatisfactory outcomes because the deviation becomes prominently visible after surgery due to the central position of the nose. Ideal nasal radix positioning has yet to be addressed. The head position affects facial asymmetry judgements; however, its effect on rhinoplasty has never been studied. This study determined the ideal nasal radix position in facial fluctuating asymmetry and investigated the effects of the natural head position (NHP) on nasal deviation perceptions.

METHODS

A survey was conducted to compare different head and nasal radix horizontal positions using images of patients who underwent augmentation rhinoplasty. Images were retouched using editing software to adjust the head and nasal radix positions. The survey was performed using questionnaires involving 3 plastic surgeons and 3 laypersons, who were asked to determine the presence of nasal deviation and select the ideal nasal radix position among the retouched images.

RESULTS

Twenty patients who underwent primary rhinoplasty were included in this study. The recognition of nasal deviation was significantly higher in the NHP than in the compensatory head position. The surgeons and the laypersons considered the midsagittal line the most appropriate position of the nasal radix.

CONCLUSIONS

Facial analysis for augmentation rhinoplasty should be performed with the patient's head in the NHP to prevent nasal deviation masking. The preferred nasal radix position in facial fluctuating asymmetry is the midsagittal line.Level of Evidence: Level V, descriptive study.

Automatic Assessment of 3-Dimensional Facial Soft Tissue Symmetry Before and After Orthognathic Surgery Using a Machine Learning Model: A Preliminary Experience

PURPOSE

An objective and quantitative assessment of facial symmetry is essential for the surgical planning and evaluation of treatment outcomes in orthognathic surgery (OGS). This study applied the transfer learning model with a convolutional neural network based on 3-dimensional (3D) contour line features to evaluate the facial symmetry before and after OGS.

METHODS

A total of 158 patients were recruited in a retrospective cohort study for the assessment and comparison of facial symmetry before and after OGS from January 2018 to March 2020. Three-dimensional facial photographs were captured by the 3dMD face system in a natural head position, with eyes looking forward, relaxed facial muscles, and habitual dental occlusion before and at least 6 months after surgery. Three-dimensional contour images were extracted from 3D facial images for the subsequent Web-based automatic assessment of facial symmetry by using the transfer learning with a convolutional neural network model.

RESULTS

The mean score of postoperative facial symmetry showed significant improvements from 2.74 to 3.52, and the improvement degree of facial symmetry (in percentage) after surgery was 21% using the constructed machine learning model. A Web-based system provided a user-friendly interface and quick assessment results for clinicians and was an effective doctor-patient communication tool.

CONCLUSIONS

This work was the first attempt to automatically assess the facial symmetry before and after surgery in an objective and quantitative value by using a machine learning model based on the 3D contour feature map.

Transverse Asymmetries of the Maxilla Even in Healthy and Apparently Symmetrical Subjects

In the formulation of an orthodontic treatment plan, the three-dimensional analysis of the dental arches represents a fundamental moment for the evaluation of all the morphological parameters necessary in order to have a correct and complete diagnosis. In this regard, the study of the dental arches on the horizontal plane is sometimes neglected or not thorough enough. When evaluating the transverse dimensions of the dental upper arche, the presence of an asymmetry is frequently found, and it means that an hemiarch is larger than the other. Furthermore, any variation in one of the three planes of space always involves an alteration also on the other two planes in order to have compensation. The morphology of a bone segment depends on various factors, mainly genetical, acquired and environmental. Regarding the environmental factors, the function determines the morphology, but this in turn determines the function. In the case of unilateral mastication, the upper maxilla will be asymmetrical, so growing patients will have compensation on other skull bones. From these considerations arises the need for a careful study of the horizontal plane of the maxilla in the presence of a malocclusion during diagnostic evaluations. These asymmetries, however, must be evaluated and quantified in the diagnostic phase in order to formulate a correct plan of treatment. The aim of this work is to demonstrate that there are almost always transverse asymmetries of the maxilla, albeit of a slight entity, even in healthy and apparently symmetrical subjects.

Patient- and 3D morphometry-based nose outcomes after skeletofacial reconstruction

Patient satisfaction with the shape and appearance of their nose after orthognathic surgery-based skeletofacial reconstruction is an important, but often overlooked, outcome. We assessed the nose-related outcomes through a recently developed patient-reported outcome instrument and a widely adopted 3D computer-based objective outcome instrument, to verify any correlation in the results produced by these tools. We collected FACE-Q nose appearance reports (2 scales) and 3D nasal morphometry (10 parameters) from patients with class III skeletal pattern and congenital cleft lip palate deformity (n = 23) or developmental dentofacial deformity (n = 23) after (>12 months) skeletofacial reconstruction. The cleft and dentofacial cohorts demonstrated significantly (p < 0.001) poorer satisfaction scores with regard to the FACE-Q nostrils scale than the normal age-, gender-, and ethnicity-matched subjects (n = 107), without any significant difference in FACE-Q nose scale. The cleft cohort had significantly (p < 0.001) smaller nasal length, nasal tip projection, and columellar angle and greater nasal protrusion, alar width, and columellar-labial angle values than the dentofacial and normal cohorts; however, there were no significant differences between the dentofacial versus normal cohorts. The FACE-Q nose and nostrils scales were significantly (p < 0.001; r = -0.26-0.27) correlated to the results of the 3D morphometric analysis, with regard to nasal length, alar width, columella angle, and columellar-labial angle parameters. This study revealed differences in satisfaction with the appearance of the nose according to the type of underlying deformity, and demonstrated a significant correlation (low correlation coefficients) between the patient-reports and 3D image-based outcome measure tools, which has implications for multidisciplinary-centered research, auditing, and clinical care.

Outcome of facial contour asymmetry after conventional two-dimensional versus computer-assisted three-dimensional planning in cleft orthognathic surgery

Computer-assisted 3D planning has overcome the limitations of conventional 2D planning-guided orthognathic surgery (OGS), but difference for facial contour asymmetry outcome has not been verified to date. This comparative study assessed the facial contour asymmetry outcome of consecutive patients with unilateral cleft lip and palate who underwent 2D planning (n = 37)- or 3D simulation (n = 38)-guided OGS treatment for correction of maxillary hypoplasia and skeletal Class III malocclusion between 2010 and 2018. Normal age-, gender-, and ethnicity-matched individuals (n = 60) were enrolled for comparative analyses. 2D (n = 60, with 30 images for each group) and 3D (n = 43, with 18 and 25 images for 2D planning and 3D simulation groups, respectively) photogrammetric-based facial contour asymmetry-related measurements were collected from patients and normal individuals. The facial asymmetry was further verified by using subjective perception of a panel composed of 6 blinded raters. On average, the facial contour asymmetry was significantly (all p < 0.05) reduced after 3D virtual surgery planning for all tested parameters, with no significant differences between post-OGS 3D simulation-related values and normal individuals. No significant differences were observed for pre- and post-OGS values in conventional 2D planning-based treatment, with significant (all p < 0.05) differences for all normal individuals-related comparisons. This study suggests that 3D planning presents superior facial contour asymmetry outcome than 2D planning.

Facial Appearance and Psychosocial Features in Orthognathic Surgery: A FACE-Q- and 3D Facial Image-Based Comparative Study of Patient-, Clinician-, and Lay-Observer-Reported Outcomes

Outcome measures reported by patients, clinicians, and lay-observers can help to tailor treatment plans to meet patients' needs. This study evaluated orthognathic surgery (OGS) outcomes using pre- and post-OGS patients' (n = 84) FACE-Q reports, and a three-dimensional facial photograph-based panel assessment of facial appearance and psychosocial parameters, with 96 blinded layperson and orthodontic and surgical professional raters, and verified whether there were correlations between these outcome measurement tools. Post-OGS FACE-Q and panel assessment measurements showed significant (p < 0.001) differences from pre-OGS measurements. Pre-OGS patients' FACE-Q scores were significantly (p < 0.01) lower than normal, age-, gender-, and ethnicity-matched individuals' (n = 54) FACE-Q scores, with no differences in post-OGS comparisons. The FACE-Q overall facial appearance scale had a low, statistically significant (p < 0.001) correlation to the facial-aesthetic-based panel assessment, but no correlation to the FACE-Q lower face and lips scales. No significant correlation was observed between the FACE-Q and panel assessment psychosocial-related scales. This study demonstrates that OGS treatment positively influences the facial appearance and psychosocial-related perceptions of patients, clinicians and lay observers, but that there is only a low, or no, correlation between the FACE-Q and panel assessment tools. Future investigations may consider the inclusion of both tools as OGS treatment endpoints for the improvement of patient-centered care, and guiding the health-system-related decision-making processes of multidisciplinary teams, policymakers, and other stakeholders.