Surface-to-Skeleton 3D Cephalometry: Estimating Hidden Skeletal Landmarks from CT-Derived External Soft-Tissue Surfaces

Existing 3D facial-landmark methods localize points on visible skin, but whether CT-defined internal skeletal landmarks can be inferred from external soft-tissue geometry remains unclear. We formulate a coordinate-consistent surface-to-skeleton task using same-acquisition CT-derived surfaces, separating estimation from optical-to-CT registration, scanner-domain, and acquisition-state effects, with coverage analyzed separately. From 240 clinical CT scans from two hospitals, we construct a locked retrospective protocol pairing CT-derived external soft-tissue point clouds with 21 skeletal landmarks and three visible soft-tissue landmarks. An integrated hierarchical point-cloud model achieves 2.97 mm mean radial error on skeletal landmarks and 3.03 mm on deep or surface-invisible landmarks in 40 held-out patients. Patient-mismatch controls support patient-specific signal beyond a fixed population configuration or global similarity alone, while coverage ablations indicate dependence on non-anterior geometry. Optical-transfer diagnostics reveal substantial coverage-related and global-configuration components, although deployable optical inference remains unresolved. These results answer the controlled feasibility question affirmatively and provide a basis for hidden skeletal landmark inference.