Fully digital occlusion planning in orthognathic surgery – A crossover study

ObjectiveThe use of virtual surgical planning (VSP) in orthognathic surgery is increasing. The aim of this study was to investigate which type of dentofacial deformity makes the surgeon choose VSP and if VSP influences the choice of surgical techniques. Furthermore, we sought to evaluate if use of VSP affects surgical time and blood loss during surgery.Material and methodsPatients having undergone orthognathic surgery and registered in the Swedish quality registry for orthognathic surgery (NROK) between 2018 and 2019 were eligible for inclusion in this study. An evaluation of the usage of VSP was performed together with an analysis of operation time and bleeding during surgery. A total of 862 patients were evaluated.ResultsOut of the 862 patients who had orthognathic surgery, 224 were VSP cases. Patients diagnosed with maxillary retrusion (p = 0.0024), maxillary vertical hyperplasia (p < 0.001), mandibular protrusion (p = 0.0031), laterogenia (p < 0.001) or craniofacial deformity (p = 0.0033) were more often digitally planned. Patients who underwent VSP and bimaxillary surgery showed a tendency of reduced operating time andless bleeding during surgery; however, the results were inconclusive.ConclusionThe present study shows that VSP was used more frequently in patients with maxillary retrusion, maxillary vertical hyperplasia, mandibular protrusion, laterogenia, and craniofacial deformity in comparison with other diagnoses. Alongside the findings that VSP cases had more diagnoses per patient and that a larger number of surgical procedures were performed in this group, this indicates a preference for using digital planning in more complex orthognathic cases.

Background: Digital workflows have transformed orthognathic surgery by enabling three-dimensional virtual surgical planning (VSP) and, more recently, artificial-intelligence-based predictive modeling. While skeletal accuracy has improved substantially, the clinical value of these tools increasingly depends on their ability to predict soft-tissue outcomes and support complex treatment decisions. Methods: This narrative review synthesizes evidence from 20 peer-reviewed studies, including systematic reviews, clinical cohorts, and machine-learning validations, to evaluate (i) the accuracy of digital patient modeling and VSP transfer, (ii) the performance of predictive models for postoperative outcomes and diagnostic classification, and (iii) associated ethical and governance considerations. Results: Automated craniofacial and dental modeling achieves submillimetric to low-millimetric accuracy, with landmark localization errors typically ≤2 mm and dental landmark errors near 0.4 mm. Clinical cohorts demonstrate that VSP transfers to surgery with mean translational deviations well below 2 mm in all planes. Predictive models estimate soft-tissue and aesthetic outcomes within clinically meaningful error margins and classify the need for orthognathic surgery with AUC values up to ~0.9 in high-risk malocclusion groups. Conclusions: Digital planning in orthognathic surgery has evolved into a precision-oriented, data-driven framework. When combined with predictive modeling and appropriate ethical governance, these technologies can enhance accuracy, personalize treatment strategies, and reduce diagnostic uncertainty, particularly in borderline and asymmetric cases.

This study aimed to compare the clinical accuracy of maxillary positioning in bimaxillary orthognathic surgery based on the method of virtual surgical planning (VSP) implementation, specifically contrasting the use of the wafer-only versus the customized guide-plate system. Thirty-four patients who underwent bimaxillary orthognathic surgery were retrospectively analyzed and divided into 2 groups: a control group (wafer-only, n=17) and a study group (wafer+guide+plate, n=17). Surgical accuracy was quantitatively evaluated by comparing the 3-dimensional coordinates of 5 maxillary landmarks between the virtual surgical plan (Tv) and postoperative cone-beam computed tomography (T1) using dedicated 3D analysis software. In addition, postoperative skeletal stability was evaluated by comparing T1 and T2. The study group showed significantly better accuracy in transverse (0.36mm versus 0.86mm) and anterior vertical dimensions (0.51mm versus 1.45mm). Both groups experienced challenges with posterior vertical positioning and sagittal accuracy. Six-month stability analysis revealed no significant differences between groups, with mean absolute changes of 0.39-1.41mm (study) and 0.44-1.39mm (control). The guide-plate system offers a clinically meaningful improvement in maxillary positioning accuracy over the wafer-only approach, particularly in complex cases requiring high precision. Both methods demonstrated comparable 6-month stability, indicating that the enhanced initial accuracy does not compromise postoperative stability.

To determine if patient outcome variables differ between conventional and virtual surgical planning of orthognathic surgery for class III asymmetry. This retrospective case-control study examined 95 patients with class III asymmetry who had been consecutively treated with at least a Le Fort I osteotomy and a bilateral sagittal split osteotomy with a surgery-first approach. Two groups were examined: 51 patients treated with conventional surgical planning and 44 with virtual surgical planning. After treatment, quantitative assessment was determined with measurements of midline symmetry, contour symmetry, and overall facial symmetry using standardized frontal photographs. Subject assessments were analyzed with questionnaires regarding self-perception of overall appearance, satisfaction with appearance, and quality of life. Conventional and virtual surgical planning resulted in significant improvements in outcomes for all patients. However, facial midline and overall facial symmetry were significantly greater for the virtual compared with the conventional group. There were no significant differences in subjective measures of appearance, satisfaction with appearance, and quality of life for patients treated with conventional or virtual surgical planning; measures were high for both groups. Conventional and virtual surgical planning of surgery-first bimaxillary orthognathic surgery resulted in quantitative and qualitative improvements in facial symmetry. Although patient satisfaction was similar for both approaches, virtual surgical planning was superior to conventional surgical planning for the improvement of midline and overall asymmetry. Improvements with virtual surgical planning in facial midline, facial contour, and overall facial symmetry are as good as or better than conventional surgical planning.

Time benefits of 3D planning in orthognathic surgery: a systematic review

To review the past year's literature regarding current computer-assisted reconstruction techniques and their outcomes. Current computer-assisted craniofacial reconstruction research is focused on data acquisition, planning, surgical and assessment phases. The major areas of interest among researchers include cosmetic surgery; cleft and craniofacial surgery; traumatic reconstruction, head and neck tumor reconstruction; and orthognathic surgery and distraction osteogenesis. Recent advances in the fields include facial analysis and planning in rhinoplasty, facial surface and bone graft volume analysis in cleft surgery, computer-guided tumor ablation and osteocutaneous reconstruction in tumor surgery, and preoperative planning and surgical assistance in orthognathic and distraction osteogenesis surgery. Research in computer-aided craniofacial surgery is progressing at a rapid rate. Rather than just the latest innovation, sound research studies are proving computer assistance to be invaluable in producing superior outcomes, especially in the fields of head and neck surgery, orthognathic surgery, and craniomaxillofacial trauma surgery. Further outcome studies and cost-benefit analyses are still needed to show the superiority of these methods to contemporary techniques.

The aim of this retrospective study was to determine whether a virtually created occlusion is as accurate as a conventionally created occlusion. Seventeen orthognathic patients were included in the study, which was conducted in a university clinic. Plaster cast models were obtained and digitized. Two experienced observers created the conventional (gold standard) and virtual occlusion to assess inter-observer variability. One observer created the conventional and virtual occlusion a second time to assess the intra-observer variability. The criterion for accepting the virtual occlusion was that the difference between the gold standard and the virtual occlusion was not larger than the intra-observer variability for the gold standard. A non-parametric Kruskal–Wallis H test was performed to detect statistically significant differences between the intra- and inter-observer groups for both the conventional and virtual occlusion. No statistically significant differences were found between the different groups. The difference between the conventional and virtual occlusion group was 0.20mm larger than the intra-observer variability of the gold standard. The virtual occlusion tool presented here can be utilized in daily clinical practice and makes the use of physical dental models redundant.

Orthognathic Surgery: A Bibliometric Analysis of the Top 100 Cited Articles

To assess the surgical accuracy of 3D virtually planned orthognathic surgery among patients with and without cleft. This retrospective cohort study included cleft and non-cleft patients with class III malocclusion who underwent bimaxillary surgery. CBCT scans were acquired before and immediately after surgery. 3D virtual surgical planning (VSP) was performed using CBCT and digitalized dentition data. All orthognathic surgeries were performed by the same surgeons using interocclusal splints. The primary outcome variable was surgical accuracy, defined as the difference between the planned and surgically achieved maxillary movements, quantified in six degrees of freedom. Analysis of covariance was used to test for intergroup differences in surgical accuracy after correcting for differences in the magnitude of planned surgical maxillary movements. Twenty-eight cleft and 33 non-cleft patients were enrolled, with mean ages of 18.5 and 25.4 years, respectively (P=0.01). No significant gender difference was present between the groups (P=0.10). After adjustment for small differences in surgical movements, no significant differences in surgical accuracy were observed between cleft and non-cleft patients. The present study demonstrates that high surgical accuracy in maxillary movements can be achieved in both cleft and non-cleft patients using VSP and interocclusal splints. Orthognathic cases with cleft can be performed with 3D VSP to obtain a satisfactory surgical accuracy.

Condylar repositioning according to digital bite registration method for virtual orthognathic surgery planning: A series of 49 consecutive patients

3-Dimensional accuracy of navigation-guided bimaxillary orthognathic surgery: A systematic review and meta-analysis

PURPOSE: Virtual surgical planning (VSP) is the gold standard for preoperative treatment planning for orthognathic surgery.1 Prior to the implementation of VSP, traditional orthognathic preoperative preparation required hours of labor and utilization of a dental laboratory. This often limited orthognathic surgery to providers with dental training. The combination of VSP and 3-dimensional printing has allowed orthognathic surgeons the ability to more accurately and efficiently create treatment plans for these cases.2 This technology has also allowed practitioners such as plastic surgeons to begin to perform orthognathic procedures. This review serves to illustrate how plastic surgeons use VSP and highlight its impact on surgical outcomes and research output within orthognathic surgery. METHODS: A literature search was conducted in the PubMed database to identify all articles published before January 2020 that report perioperative use of VSP technology in orthognathic surgeries. Only articles that were written in English, involved operations on live human patients, and used VSP to plan or assist with orthognathic surgery were included in the analysis. All articles that fit inclusion criteria were reviewed to determine the year of publication, type of orthognathic surgery performed, how VSP was used, and the primary outcomes measured. RESULTS: A total of 419 publications regarding VSP in orthognathic surgery resulted from initial search. Of them, 244 publications were authored by oral and maxillofacial surgeons, 28 publications by plastic surgeons, and 34 by surgeons with training in both fields. TEMPORAL TREND OF PUBLICATIONS: Prior to the late 1990s, VSP in orthognathic surgery publications was primarily authored by oral and maxillofacial surgeons. Plastic surgeons first began publishing on VSP technology for orthognathic surgery in 1998. Since then, there has been a rising trend in plastic surgery usage of VSP paralleled by increasing VSP publications in the field, with 2 publications before the year 2010 (7.2%), 9 from 2010 to 2015 (32%), and 18 between 2015 and 2019 (64%). CATEGORIES OF PUBLICATIONS: Most publications from oral and maxillofacial trained surgeons highlight optimal positioning of craniofacial bones, anticipated stability and functionality of occlusion, and the interplay between orthodontic treatments and orthognathic surgery. In contrast, plastic surgeon authored papers often discuss postoperative facial aesthetics by ensuring facial symmetry and treatment especially in the cases of congenital craniofacial abnormalities like cleft lip/palate, Treacher-Collins, and hemifacial microsomia. CONCLUSIONS: VSP is an increasingly utilized tool that reduces the workflow without compromising accuracy and outcomes in orthognathic surgery. This is the first paper to create a temporal relationship between a new technology and the emergence of plastic surgeons into a field typically predominated by oral and maxillofacial surgeons. As plastic surgeons become more familiar with this technology, they have produced literature that provides alternative perspectives on orthognathic surgery that will push the field forward. REFERENCES: 1. Langdon J, Patel M, Brennan P. Operative Oral and Maxillofacial Surgery. 2nd ed. CRC Press; 2010. 2. Baker SB, Goldstein JA, Seruya M. Outcomes in computer-assisted surgical simulation for orthognathic surgery. J Craniofac Surg. 2012;23:509–513.

Orthognathic surgery (OGS) is a transformative procedure that enhances function and aesthetics. Recent advancements in virtual surgical planning (VSP) of OGS, particularly with 3-dimensional (3D) simulation and intraoral scanning, have improved surgical accuracy and postoperative stability. However, complex cases, such as edentulous jaws, present significant challenges. These cases may lead to increased complications and difficulties in surgical planning. This report introduces an innovative VSP method that incorporates dentures into 3D simulation for challenging cases of edentulous and asymmetric jaws. The composition of dentures into VSP is achieved by performing intraoral scans while the patient is wearing the dentures. Skeletal evaluations are based on bone-derived reference points (Sella, Nasion, Point A, Point B) independent of teeth. Postoperative evaluations using cone beam computed tomography showed a close alignment between the planning of VSP and actual outcomes, validating the accuracy of the VSP method that includes dentures. The differences in displacement of point A and point B between the planned and postoperative results were each <2mm in 3 axes. ANB was markedly improved compared with preoperative. The advancement at point A was slightly insufficient due to the influence of the pharyngeal flap, leading to smaller SNA and ANB than planned. Root-mean-square deviation and color map were also <2mm. This study confirms that integrating dentures into VSP significantly enhances the precision and effectiveness of the surgical procedure, ultimately improving mastication and facial aesthetics in complex craniofacial cases.

First results with complete 3D planning in orthognathic surgery

Computer planning in orthognathic surgery