Journal of the Formosan Medical Association 120 (2021) 2100e2112

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Original Article

Outcome of full digital workflow for

orthognathic surgery planning in the
treatment of asymmetric skeletal class III
deformity
Cheng-Ting Ho a,b,*, Hsin-Chih Lai a,b, Hsiu-Hsia Lin b,
Rafael Denadai b,c, Lun-Jou Lo b,c

a
Division of Craniofacial Orthodontics, Department of Dentistry, Chang Gung Memorial Hospital,
Chang Gung University, Taoyuan, Taiwan
b
Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan,
Taiwan
c
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung
University, Taoyuan, Taiwan

Received 16 July 2020; received in revised form 25 March 2021; accepted 3 May 2021

KEYWORDS Background/purpose: Studies have reported the advantages of digital imaging-assisted orthog-
Facial asymmetry; nathic surgery planning, but there is scarce information about a full digital planning modality.
Orthognathic surgery; This study evaluated the 3D cephalometric-based and patient-reported outcomes of a full dig-
Simulation; ital workflow for orthognathic surgery planning in the treatment of asymmetric maxillomandib-
Planning; ular disharmony.
Outcome Methods: A postoperative 3D image dataset of 30 Taiwanese Chinese patients with asymmetric
skeletal Class III deformities who underwent full digital planning for two-jaw surgery were
retrieved from the authors’ database. The 3D cephalometric data (dental, skeletal, and soft
tissue evaluations) were compared to the ethnicity-matched 3D cephalometric normative
values. Patient-reported outcome measure tools regarding postoperative overall appearance
and satisfaction with facial areas (ranging from 0 to 100 and 0 to 10, respectively) were admin-
istered. The number of needed or requested revisionary surgery was collected.
Results: No difference (all p > 0.05) was observed between the orthognathic-surgery-treated
patients and the normative value for most of the tested 3D cephalometric parameters, with
the exception (p < 0.05) of three mandible and occlusal-plane-related parameters. Both
patient-reported outcome measure tools showed that patients’ satisfaction with their postop-
erative appearance was high for overall face (89.7
4.5) and specific facial regions (nose,
7.1
1.3; lip, 8.3
1.6; upper gum, 8.5
1.2; cheek, 8.8
1.1; chin, 9.2
1.2; and teeth,
9.3
0.8), with no need for revisionary surgery.

* Corresponding author. Craniofacial Research Center, Chang Gung Memorial Hospital, 5 Fu-Shin Street, Kwei Shan, Taoyuan, 333, Taiwan.
E-mail address: [email protected] (R. Denadai).

https://doi.org/10.1016/j.jfma.2021.05.014
0929-6646/Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 Journal of the Formosan Medical Association 120 (2021) 2100e2112

Conclusion: The patients treated with a full 3D digital planning-assisted two-jaw surgery had a
similar 3D dental relation, facial convexity, and symmetry compared to healthy ethnicity-
matched individuals, and they reported higher satisfaction levels with their postoperative
facial appearance results.
Copyright ª 2021, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Introduction Materials and methods

Orthognathic surgery (OGS) has been considered an effec- This is a retrospective study performed on skeletal mature
tive intervention for managing difficult clinical scenarios, Taiwanese Chinese patients (n Z 30; female Z 53%; mean
such as the abnormal maxillaemandibular relationship age of 24 years) with an asymmetric Class III deformity
associated with visible facial asymmetry.1,2 Any preopera- (concave facial profile, negative A pointenasioneB point
tive misdiagnosis and inaccurate planning could limit the angle, negative overjet, dental midline discrepancy,
accomplishment of a successful functional occlusion and occlusal plane canting, cheek asymmetry, or chin deviation
facial appearance result, with the potential need for >4 mm), who consecutively underwent computer-assisted
redoing the OGS or revisionary procedures.3 Digital imaging modified surgery-first two-jaw OGS treatment by the same
technology has then been recognized as a critical factor for orthodontist and surgeon professionals (CTH and LJL) be-
proper diagnosis and planning, with the consequent tween July 2016 and July 2017. These patients have been a
achievement of satisfactory results in the surgical correc- part of different orthognathic surgery-related studies per-
tion of asymmetric maxillomandibular disharmony.4e7 formed in this center previously.13,14,18 The postoperative
Various components of OGS planning have been 3D cephalometric outcome of full digital planning modality
described in the virtual environment, including digital- has been published previously.14 Exclusion criteria were (1)
imaging-based dental impression, occlusion set-up, surgi- presence of a cleft, syndromic diagnosis; (2) a history of
cal simulation, and surgical wafer fabrication.8e13 By previous OGS; (3) a history of facial trauma; or (4) incom-
combining these previously isolated studies,8e13 full digital plete follow-up (<12 months after debonding).
planning could replace the conventional planning (manual- The study was reviewed and approved by the Institu-
based dental impression, occlusion set-up, and wafer tional Review Board, Chang Gung Medical Foundation (IRB
fabrication and paper surgery-based simulation). However, No 201601986B0C501).
detailed technical descriptions of full digital planning have
been insufficient to date.14 Full digital workflow for planning
Our team has progressively adopted the cone beam
computed tomography (CBCT)-derived three-dimensional All of the included patients received full digital OGS plan-
(3D) data in OGS care, with initial experiences using a ning (Fig. 1), including virtual dento-facial image acquisi-
hybrid planning modality, that is, 2D cephalometric tracings- tion, computer-assisted shared-decision making processes,
based stone model surgery transferred to the virtual virtual occlusion set-up, virtual surgical simulation, and 3D
environment.6,7,10,12,13 Our current approach integrates printed surgical wafer.6e10,19
otherwise isolated digital steps6e10,12,14 of planning in order An i-CAT CBCT scanner (Imaging Sciences Interna-
to compose a full digital workflow for OGS planning.14 This tional, Hatfield, PA, USA) was adopted to acquire two-week
full digital planning modality has demonstrated no significant preoperative 3D facial and dental images, with a standard
differences in 3D cephalometric parameters when compared low-dose protocol (120 kV, 5 mA, 50 Hz, 0.4  0.4  0.4-mm
to the hybrid planning (i.e., conventional planning trans- voxel size, 40-s scan time, and 22  16-cm field of view).
ferred to 3D environment).14 However, ethnic-matched 3D The patients’ heads were positioned with the Frankfort
cephalometric normative data15e17 were not considered for horizontal plane parallel to the ground, and they were
the outcome measurement. Moreover, the technical details instructed not to swallow, to keep their mouth closed, and
of our current OGS planning using a full digital workflow have to maintain a centric occlusion bite. A 3Shape TRIOS 3
not been fully described to date. Understanding the various intraoral scanner (3Shape, Copenhagen, Denmark) was used
components constituting the full digital workflow for OGS to acquire two-week preoperative digital impressions of the
planning and its postoperative outcomes could provide upper and lower dental arches (Fig. 2) under standard
helpful information to assist the orthodontistesurgeon resolution, with calibration of the device before all of the
interaction in implementing this planning modality into scanning procedures. Using a 3D image dataset (patient-
their own OGS care. specific 3D cephalometric tracing and 3D cephalometric
The purposes of this study were to (1) describe our full norms of Chinese ethnicity), a comprehensive diagnosis of
digital workflow for OGS planning, (2) assess its results the actual dento-skeletofacial deformity was established.
using patient-reported perception of postoperative facial Considering this objective diagnostic information associ-
appearance, and (3) compare the postoperative 3D cepha- ated with the patients’ opinions, a focused-problem list
lometric results with ethnic-matched 3D normative data. was formulated to guide the virtual treatment planning.

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Figure 1 Flowchart displaying the digital imaging-assisted orthognathic surgery planning.

surgical feasibility (Fig. 6). Only the final surgical occlusion

was defined, as we did not use intermediate occlusion for
the OGS procedure.20,21
For the virtual surgical planning, the maxilla and
mandible segments were repositioned as a unique 3D model
(named the maxillomandibular complex), with no change in
the final virtual surgical occlusion. Through translational
and rotational (pitch, yaw, and roll directions) repositioning
of the maxillomandibular complex, the planned balance
between occlusal function and facial appearance was ach-
ieved in the virtual environment (Fig. 7).
Figure 2 Preoperative high-resolution surface scans of the The computer-generated 3D surgical wafers were then
full upper and lower dental arches (digital dental impression) fabricated using only the final surgical occlusion set-up as a
revealing the actual dental anatomy. template (Fig. 8). The thickness of the digitalized dental
image data set was adjusted in the OrthoAnalyzer software
package (3Shape, Copenhagen, Denmark) and then printed
All of the facial and dental scans were imported into 3D (Objet30 OrthoDesk 3D Printer, Stratasys Ltd., Israel) using
imaging software (Dolphin Imaging; Dolphin Imaging and a biocompatible PolyJet photopolymer material (MED610;
Management Solutions, Chatsworth, California, USA) as Stratasys Ltd., Israel). No 3D printed custom-made surgical
Digital Imaging and Communications in Medicine (DICOM) guides or fixation plates were adopted for the treatment of
and Standard Tessellation Language (STL) files, respec- the included patients.
tively. After the reorientation of the 3D facial model
(Fig. 3), the osteotomy lines were defined for the maxilla
and mandible segments including Le Fort I, bilateral sagittal Transfer of the digital planning into actual surgery
split osteotomy, and genioplasty (Fig. 4). The CBCT dental
arch images were superimposed and replaced by the digital The 3D printed surgical wafer, simulated image-derived
dental images using the artifact-resistant surface-based numerical and visual (bone positioning and spatial rela-
registration method. To set up the virtual occlusion, a tionship between osteotomized bone segments) informa-
seven-step protocol was followed,8 with steps one to six tion, bone-guided measurements (medial and lateral
being adopted in order to decide on the repositioning of the maxillary pillars bilaterally), and modified face bow-based
teeth anteroposteriorly, vertically, and transversely midline checking (nasal dorsum and tip, lips, maxilla,
(Fig. 5), and step seven used to define how this dental dental arches, and chin points) were used to transfer the
positioning impacted the balance between dental occlusion full digital planning to the patient in the operating theater
and facial appearance, as well as to outline any in- (Fig. 9). After the maxillomandibular complex and proximal
compatibility between the orthodontic planning and mandible ramus were repositioned to the desired position,

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Figure 3 Cone beam computed tomography (CBCT)-derived 3D craniofacial model reoriented according to the midsagittal and
Frankfort horizontal planes.

Figure 4 3D craniofacial models in frontal and profile views with CBCT-derived dental arches replaced by scanned digital dental
models, cephalometric parameters revealing an asymmetric Class III deformity, and accurate osteotomy simulation (1-piece Bell’s
Le Fort 1 maxillary osteotomy, modified ObwegesereDal Pont’s bilateral sagittal split osteotomy, and genioplasty).

the Le Fort I and mandible ramus segments were fixed with revision surgery was defined as any revisionary bone and/or
miniplates and screws, and bicortical screws, respectively. soft tissue procedure requested or required to improve the
Genioplasty was finally executed as planned. No interposi- occlusal, maxillary, mandibular, and/or chin morphology
tional bone graft was used in interventions requiring the within the follow-up.
maintenance of intersegmental gaps. The orthodontic and For the 3D cephalometric analysis, the postoperative
surgical principles adopted by this team have previously CBCT-derived 3D facial bone and soft tissue models were
been described.20e24 retrieved from the Craniofacial Research Center data-
base.13,14,18 All of the 3D anatomical landmarks, reference
planes, and cephalometric measurements (dental relation,
Outcome analysis skeletal evaluation in the sagittal and frontal views, and soft
tissue examination) parameters were established based on
All of the included patients were clinically examined by our previous descriptions (Fig. 10; Supplementary Table
multidisciplinary team for skeletofacial surgery-related 1).18,25e27 All of the cephalometric analyses were per-
complications or need for revision surgery. Need for formed twice in intervals of 2 weeks, by the same

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Figure 5 Virtual surgical occlusion set-up based on a step-by-step approach with real-time visualization and evaluation. The
virtual occlusion is defined by moving the distal mandible segment to the fixed maxilla (original position), with the midpoint of the
lower incisor teeth defined as the center of movement (Right). Before and after setting the final occlusion with the dental midline
alignment, overjet correction, overbite correction, yaw rotation in the basal view, pitch rotation in the profile view, and roll
rotation in the frontal view (steps 1 to 6, respectively). For step 7, please, refer to Fig. 6 (Center). Basal view showing the
relationship between the upper and lower dental arches (Right). The occlusogram with a colormap tool used to evaluate and avoid
dental collision, detect specific locations of the dental contact points, and the magnitude of contact depth. The depth of dental
contact is set between 0 and 0.5 mm (i.e., contact depth in normal occlusion), with the colormap indicating a green color. If there
is over maximal crossing in the contact depth (>0.5 mm), the colormap indicates a red color. At least three contact points (green
color) are required in the occlusion, preferably one on the anterior region and two on the bilateral posterior area.

investigator, using the SimPlant O&O software package For the patient-reported outcome-based analysis, all
(Materialize, Leuven, Belgium). The Euclidean distance be- patients completed two validated scales (Mandarin Chinese
tween the first and second landmark coordinates was versions)28e30 addressing the perception of appearance
calculated. Measurement error analysis was conducted during the postoperative (>12 months after debonding)
based on the following formula: D Z O(Dx)2 þ (Dy)2 þ (Dz),2 clinical appointments. The Overall Appearance Rating tool
where D is the total error for each landmark, Dx is the dif- is a self-rating of a patient’s own overall appearance,
ference in the X coordinate, Dy is the difference in the Y ranging from 0 to 100. The Satisfaction of Facial Areas tool
coordinate, and Dz is the difference in the Z coordinate.27 is a self-rating of a patient’s own satisfaction about
The intra-evaluator reliability was considered excellent different facial regions (cheek, chin, nose, lip, upper gum,
(Pearson correlation coefficients Z 0.88e0.99; all p < 0.01), and teeth), ranging from 0 to 10, with 1 being very dissat-
with a clinically acceptable measurement error isfied, 5 being neutral, and 10 being very satisfied. Both
(0.4
0.1 mm; Supplementary Table 2). 3D cephalometric scales asked patients to answer items with facial appear-
normative data from healthy Chinese individuals15e17 were ance in mind, with higher score values indicating a greater
adopted for the comparative analysis. satisfaction with appearance.28e30

Figure 6 3D craniofacial models in the frontal and profile views after step 6 of the virtual occlusion set-up (Fig. 5) for checking
how the mandible repositioning impacts the balance between the dental occlusion and the overall facial appearance, as well as the
surgical feasibility (step 7). For example, as large rotational movement of the mandible segment could affect the satisfactory
repositioning of the maxillomandibular complex or determinate interference between the bony structures at the pterygoid
maxillary junction and mandibular ramus areas, and the virtual occlusion could be immediately refined to solve the issue. For the
actual dentofacial deformity, please, refer to Fig. 4.

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Figure 7 Through an orthodontistesurgeon collaboration and real time 3D bony movement and cephalometric analysis using 3D
cephalometric norms as reference, the virtual surgical simulation of single-splint two-jaw orthognathic surgery technique (1-piece
Le Fort 1 osteotomy for maxillary advancement and bilateral sagittal split osteotomy for mandible setback using the final occlusion)
is tailored to patient-specific clinical requirements. To achieve a balanced skeletal harmony (facial convexity and facial proportion)
and symmetry (occlusal plane, dental and chin midlines, and mandibular body contour), the maxillomandibular complex is
repositioned in translational (advancement, shift, and intrusion) and rotational (pitch clockwise, roll counterclockwise, and yaw
counterclockwise) directions, the proximal ramus segments are adjusted with a roll rotation, and the chin area is refined with
reduction genioplasty. For the actual dentofacial deformity, please, refer to Fig. 4.

Figure 8 Surgical wafer production in a virtual environment using digital images of final occlusion, with a number of custom-
izable features, such as minimizing/maximizing occlusal overlap, adjusting the size of palatal strutting, and creating holes for
intraoperative fixation, as needed.

Among the previously described potential advantages samples t-test was adopted for comparison between OGS-
(i.e., patient discomfort, reuse possibility, storage space treated patients and healthy ethnicity-matched in-
needs, and time savings parameters) of digital-imaging- dividuals. A Bonferroni correction was applied for multiple
based OGS planning over the conventional planning mo- comparisons. Two-sided values of p < 0.05 were considered
dality,8,7,10,14 the members of our multidisciplinary team, statistically significant. All of the analyses were performed
composed of health informatics specialists, biomedical using SPSS Version 17.0 (IBM, Armonk, USA).
engineers, craniofacial orthodontics, plastic surgeons, and
fellows (craniofacial orthodontics and craniofacial surgery),
discussed and elected by consensus a key advantage for the Results
full digital planning model.
All of the included patients received modified surgery-first
Statistical analysis two-jaw OGS treatment for the correction of Class III
deformity associated with visible asymmetry, with no
It was verified that the data were normally distributed by request or indication for revisionary surgery at least 1 year
using the KolmogoroveSmirnov test. An independent after debonding (Figs. 11 and 12).

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Figure 9 Simulated image-derived numerical (medial and lateral maxillary pillars bilaterally) and visual (bone positioning and
spatial relationship between osteotomized bone segments) information and 3D printed surgical wafer used to transfer the full
digital planning to the actual surgery. The virtual-imaging-based position (distance from the buccal cortex and the anterior
mandibular margin) of the inferior alveolar nerve (green color) is applied for ramus splitting.

Figure 10 Anatomical landmarks and reference planes adopted for the 3D cephalometric analysis.

No difference (all p>0.05) was observed between the conventional planning (2D cephalometric images, paper-
orthognathic surgery-treated patients and the normative and dental-cast-based simulation, and manual fabrication
value for most of the tested 3D cephalometric parameters, of surgical wafer).6,7,31e35 Along with the improved reli-
with the exception (p < 0.05) of three angle parameters ability and reproducibility of each step of OGS planning in
(L1-MP, SN-MP, and OP-FH; Tables 1e3). the virtual setting, computer-assisted OGS planning has
Both patient-reported outcome measure tools showed increased in acceptance and popularity over the past
that patients’ satisfaction with their postoperative recent years.36e39 The virtual surgical simulation also adds
appearance was high (Table 4). predictability and efficiency to the surgical performance
The multidisciplinary team elected, by consensus, the by identifying where bony overlaps and gaps exist, all
time savings parameter as a key advantage of fully digital before surgery.1,10,21,24 Based on this accumulated evi-
OGS planning compared with the conventional OGS plan- dence, the traditional paper- and dental-cast-based
ning modality. planning could be completely replaced by the full digital
planning by utilizing medical imaging data (patient-spe-
cific anatomy and cephalometric normative value) from a
Discussion CBCT, as well as dental arch anatomy data from a laser
scanner, accurate positioning of osteotomy lines and
Both in vivo and in vitro studies have reported a compa- maxillaemandibular movements from a 3D software, and
rable or even higher accuracy and precision for digital precise surgical wafer production from a 3D printer.
imaging-assisted OGS planning (3D facial and dental However, practical descriptions of a total virtual working
models, virtual occlusion set-up, surgical simulation, and environment for OGS planning and its outcome analysis
computer-generated 3D surgical wafer) compared with have been insufficient to date.14

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Figure 11 The preoperative intraoral and facial views of a patient with an asymmetric skeletal Class III deformity.

Figure 12 The postoperative intraoral and facial views with improved dental relation, facial convexity, and symmetry.

Over the past of four decades of OGS care in this center, digital workflow, as well as by assessing its outcomes by
we have progressively described our experience in adopt- using clinician-centered outcome measures (3D cephalo-
ing, modifying, and improving the digital workflow in the metric parameters and need for revisionary surgery) and
OGS workup.40,41 This study contributes to this previous patient-reported outcome measures (Overall Appearance
literature by enhancing the technical description of a full Rating and Satisfaction of Facial Areas) tools. We have

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Table 1 Comparison analysis for 3D cephalometric mea- Table 2 Comparison of postoperative measurement with
surement for males and females (nZ30). 3D cephalometric norms for male patients (nZ15).
3D parameters Postoperative 3D p 3D parameters Postoperative 3D p
3D cephalometric 3D cephalometric
cephalometry norms of cephalometry norms of
Chinese adults Chinese adults
Dental Dental
UI-SN ( ) 109.5
5.7 112.7
6.1 0.105 UI-SN ( ) 106.32
6.14 112
5.2 0.006
L1-MP ( ) 86.9
7.2 97.5
6.7 <0.001 L1-MP ( ) 84.42
7.22 98.8
7.6 0.000
U1-Nv (mm) 6.5
3.6 6.9
3.0 0.378 U1-Nv (mm) 6.04
4.89 7.2
3.6 0.425
U1-MSP (mm) 0.7
0.6 0.9
0.7 0.371 U1-MSL (mm) 0.79
0.8 0.9
0.35 0.617
L1-MSP (mm) 1.2
1.3 1.4
1.0 0.518 L1-MSL (mm) 1.29
1.37 1.4
0.39 0.764
Overjet (mm) 3.4
0.7 3.6
3.4 0.418 Overjet (mm) 3.93
0.94 3.6
2.3 0.505
Skeletal Skeletal
SNA ( ) 84.2
3.7 84.9
4.3 0.386 SNA ( ) 83.54
2.27 84.9
3.22 0.118
SNB ( ) 81.8
3.3 81.4
3.8 0.585 SNB ( ) 80.79
3.06 81.8
3.4 0.327
ANB ( ) 3.1
1.4 3.3
1.6 0.934 ANB ( ) 2.82
1.97 3.52
1.43 0.236
SN-MP ( ) 37.5
4.7 33.6
5.6 0.020 SN-MP ( ) 37.86
4.1 33.53
5.75 0.009
OP-FH ( ) 13.1
3.3 8.6
3.4 <0.001 OP-FH ( ) 10.96
4.3 8.7
3. 0.084
N-A-Pog ( ) 2.9
4.5 3.0
2.1 0.796 Angle convexity 2.67
3.95 3.1
2.9 0.712
A-Nv (mm) 1.0
2.8 1.1
2.7 0.694 ( )
B-Nv (mm) 3.0
4.8 3.9
4.3 0.346 A-Nv (mm) 0.96
2.21 1.2
2.1 0.731
Pog-Nv (mm) 2.8
4.6 3.1
6.5 0.605 B-Nv (mm) 3.54
5.15 4
3.4 0.757
Me-MSP (mm) 1.1
1.4 1.0
0.6 0.601 Pg-Nv (mm) 2.86
4.9 3.3
6.3 0.8
N-ANS:ANS-Me 0.7
0.2 0.8
0.1 0.949 NANS:ANS-Me 0.81
0.09 0.83
0.08 0.475
Occlusal 0.8
1.0 0.5
0.7 0.081 Me-MSL (mm) 0.57
1.22 1.
0.7 0.221
canting ( ) Occlusal 0.93
1.25 0.56
0.63 0.293
Soft tissue canting ( )
Upper lip to 0.4
0.1 0.5
0.0 0.144 Soft tissue
lower lip Upper lip to 0.5
0.05 0.52
0.05 0.221
(mm) lower lip
Upper lip to 1.5
1.6 1.7
2.3 0.621 (mm)
E-line (mm) Upper lip to 1
1.67 1.68
1.19 0.175
Lower lip to 1.2
1.8 1.8
2.9 0.183 E-line (mm)
E-line (mm) Lower lip to 1.68
1.39 1.8
1.42 0.789
G-Sn-Pog ( ) 10.7
3.4 11.6
4.4 0.407 E-line (mm)
Sn’-Gv (mm) 5.8
2.8 6.5
3.1 0.376 Facial 10.04
4.38 12.6
4.1 0.075
Pog’-Gv (mm) 0.6
4.6 0.6
5.1 0.850 convexity
Data presented as mean
standard deviation;  , degree; mm, ( )
millimeters; For definitions, please, refer to Supplemental Sn’-G’vert 7.61
4.28 6.92
2.1 0.562
Digital Content 1. (mm)
Pg’-G’vert 2.01
2.04 0.5
3.57 0.088
(mm)
Data presented as mean
standard deviation;  , degree; mm,
combined these clinician-centered and patient-reported
millimeters; For definitions, please, refer to Supplemental
outcome measure tools, as each particular metric pro- Digital Content 1.
vides valuable and complementary information to another
metric.42,43
This study shows no difference between the OGS-treated
patients and healthy ethnicity-matched individuals for most parameters were observed, which could be explained by
of the 3D cephalometric parameters, revealing that the our dental management protocol (modified surgery-first)
described OGS approach using the full digital planning de- and the adoption of the pitch clockwise rotation of the
terminates a satisfactory change in the dental relation-, maxillomandibular complex in order to improve paranasal
facial convexity-, and symmetry-related parameters. Key fullness and create a more convex profile when treating a
midsagittal anatomical landmarks (U1, L1, and Me) and the skeletal Class III deformity.13,45,46
occlusal canting parameter presented an adequate Previous investigations have demonstrated that the
correction in the frontal view, with all of the postoperative improvement of the facial appearance is the primary
data within the clinically acceptable discriminative motivation of patients seeking OGS treatment.28,47 This
threshold values ( < 2 mm and < 2 ) of asymmetry identi- suggests that facial appearance should be considered and
fication across the different facial regions.44 Moreover, addressed by multidisciplinary teams during the preopera-
significant differences for the L1-MP, SN-MP, and OP-FH tive workup, surgical execution, and measurement of the

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Table 3 Comparison of postoperative measurement with Table 4 Patient-reported outcome of satisfaction with
3D cephalometric norms for female patients (nZ15). postoperative appearance.
3D parameters Postoperative 3D p Scales Orthognathic surgery-treated
3D cephalometric patients
cephalometry norms of Total Male Female
Chinese adults (n Z 30) (n Z 15) (n Z 15)
Dental Overall 89.7
4.5 90.3
5.5 89.4
8.4
UI-SN ( ) 110.44
6.49 111
8.2 0.806 appearance
L1-MP ( ) 87.68
6.55 97.1
6 0.000 (0e100) a
U1-Nv (mm) 6.26
3.04 6.5
3.1 0.807 Facial area satisfaction (0e10) a
U1-MSL (mm) 0.6
0.4 0.8
0.41 0.133 Teeth 9.3
0.8 9.4
0.8 9.3
0.4
L1-MSL (mm) 1.44
1.13 1.3
0.43 0.648 Chin 9.2
1.2 9.3
1.6 9.1
1.9
Overjet (mm) 3.03
0.78 3.5
1.9 0.256 Cheek 8.8
1.1 8.9
1.0 8.8
2.1
Skeletal Upper gum 8.5
1.2 8.5
1.1 8.4
1.4
SNA ( ) 84
1.62 84.8
2.27 0.190 Lip 8.3
1.6 8.4
1.7 8.1
1.9
SNB ( ) 81.58
2.2 81.1
3.17 0.561 Nose 7.1
1.3 7.3
1.9 7.0
1.8
ANB ( ) 2.32
1.39 3.2
1.69 0.078
SN-MP ( ) 36.15
3.71 33.65
4.36 0.059 Data presented as mean
standard deviation.
a
Higher scores indicate higher postoperative satisfaction.
OP-FH ( ) 11.06
3.21 8.5
2 0.011
Angle convexity 2.67
3.67 2.9
3.5 0.843
( )
A-Nv (mm) 1.41
1.84 1.1
1.9 0.604
B-Nv (mm) 2.85
2.73 3.9
2.9 0.248 induced nasal width and nasal tip rotation changes. Other
Pg-Nv (mm) 0.26
3.46 2.97
5.5 0.058 groups performing rhinoplasty during OGS could further
NANS:ANS-Me 0.8
0.04 0.78
0.08 0.278 address this issue.
Me-MSL (mm) 0.75
0.81 0.9
0.8 0.563 In this study, no need or request for revisionary surgery
Occlusal 0.65
0.68 0.62
0.59 0.886 was observed during follow-up, demonstrating that the
canting ( ) described full digital planning model resulted not only in
Soft tissue the achievement of the desired facial symmetry aligned
Upper lip to 0.49
0.08 0.48
0.04 0.653 with the enchantment of appearance, but also in successful
lower lip functional results of the occlusion. The number of revi-
(mm) sionary surgeries after OGS treatment was a relevant factor
Upper lip to 1.24
2.11 1.82
1.23 0.337 for this center in order to implement quality improvement
E-line (mm) changes.13,40,41 The introduction of 3D imaging technology
Lower lip to 1.56
1.71 1.7
1.04 0.774 into our OGS care has allowed for the formulation of a
E-line (mm) tailored therapeutic plan to address all of the diagnosed
Facial 10.16
3.4 11.32
3.42 0.295 and requested clinical issues in a unique surgical proced-
convexity ure; it draws on accurate patient-derived information with
( ) a careful and comprehensive examination of the skeletal,
Sn’-G’vert 5.94
2.86 6.28
2.1 0.687 dental, and facial soft tissue components of deformity, as
(mm) well as the patients’ complaints and requests in a shared
Pg’-G’vert 2.36
3.32 0.6
2.8 0.094 decision-making process between the patient and the
(mm) orthodonticesurgical team. This preoperative contempla-
tion of the patients’ opinions and expectations, which
Data presented as mean
standard deviation;  , degree; mm,
focusses profoundly on facial appearance, has assisted in
millimeters; For definitions, please, refer to Supplemental
Digital Content 1. surgical execution based on patient-specific planning, with
a remarkable reduction in the number of revisionary sur-
gical interventions.13,40,41
Overall, our results reveal that it is clinically feasible to
OGS outcome. Our current long-term follow-up evaluations apply a full digital workflow for OGS planning in the chal-
after debonding revealed that OGS-treated patients had lenging scenario of asymmetric maxillomandibular dishar-
high levels of satisfaction with their overall facial appear- mony, with no compromise of surgical achievability.
ance and specific facial areas. The nasal region had the However, our previous investigation showed that full digital
lowest score, which could be secondary to OGS-induced planning is not superior to the hybrid planning model when
nasal morphological changes, such as altering the width considering the cephalometric measurements and patients’
and increasing the tip rotation angle, which are associated perception of results.14 Further comparative studies
with a poor appearance by Asian individuals.48,49 Our find- addressing potential differences between the hybrid and
ings are coincident with post-OGS data from previous in- full digital models of OGS planning would constitute an
vestigations using similar patient-reported outcome evidence-based foundation for assisting multidisciplinary
measure tools but employing a hybrid model for OGS teams in decision-making processes of adapting the best-
planning.29,30 Rhinoplasty could be needed to adjust OGS- suited planning model to their own environment of

2109
 C.-T. Ho, H.-C. Lai, H.-H. Lin et al.

resource availability, pursuing the achievement of high- variable stages of the learning curve could be targeted in
quality, patient-centered OGS care. future studies.
Moreover, we have previously proposed that members of
multidisciplinary teams should also consider additional
Conclusion
factors (i.e., storage needs, convenience for data reuse,
patient comfort, overall planning time, availability, and
Patients treated with modified surgery-first single-splint
costs) when selecting the planning modality (conventional
two-jaw surgery using full 3D digital planning had similar 3D
versus digital models) and allocating resources.14 Digital-
dental relation, facial convexity, and symmetry compared
imaging-based OGS planning could avoid patient discom-
to healthy ethnicity-matched individuals, and the satis-
fort during the alginate impression, the risk of breaking
faction with their postoperative facial appearance results
dental casts, and the risk of loss of the occlusion set-up
was high.
over time. The digital environment also allows for the
prompt assessment of the available data (raw or simulated
3D models), with no requirement of a physical place to Financial disclosure
store dental casts and paper- and model-based surgery
materials, and no wastage of impression materials as well None of the authors have any sources of financial or other
as no use of impression trays, adhesives, or gypsum, support or any financial or professional relationships that
therefore being environmentally friendly. There is an may pose a competing interest.
expanding number of companies developing virtual surgical
solutions, with many commercially available CBCT scan-
ners, intraoral scanners, 3D printers, and 3D software
Statement of Institutional Review Board
packages, but restrictions related to cost remain a approval
hampering factor for the widespread use of virtual planning
across the globe, mainly in low-resource regions. A growing The study was reviewed and approved by the Institutional
body of cost-effectiveness analyses in favor of computer- Review Board, Chang Gung Medical Foundation
assisted OGS care36e39 could support government, health- (201601986B0C501).
care systems and organizations, and other stakeholders in
affording 3D technology-related knowledge and funding for Authorship participation and contribution
clinicians’ development.
In this study, our multidisciplinary team defined, by
Conception and design: CTH, HCL, HHL, RD, and LJL.
consensus, that time saving is a key advantage of the full
Acquisition, analysis, and interpretation of data: CTH, HCL,
digital workflow compared with the conventional planning
and HHL. Drafting the article: CTH and HCL. Critically
modality. The literature has revealed that the overall time
revising the article: HHL, RD, and LJL. Study supervision:
required for planning can be significatively reduced by
RD and LJL. Reviewed submitted version of manuscript: all
using the virtual setting.39,50e53 However, no formal anal-
authors.
ysis has objectively compared the full digital workflow
against other planning modalities, which is deserving of
additional investigation. Future research could also define Declaration of competing interest
clinicians’ time burden using the full digital planning, and
define any potential impact of time effectiveness on the
The authors have no conflicts of interest relevant to this
final surgical results.
article.
The potential limitations of this study should be
addressed. This study is a further extension of our imple-
mentational process of 3D imaging technology in OGS Acknowledgement
care.6e10,12,13,40,41 Our findings are based on a specific
subgroup of young adult patients with a skeletal Class III The authors would like to thank Lien-Shin Niu and Chun-Hao
deformity and visible facial asymmetry, managed by the Liao for their assistance during the imaging process, and
same orthodontic and surgeon professionals who have the Center for Big Data Analytics and Statistics (Chang Gung
transitioned from traditional planning to a more accurate Memorial Hospital) for their assistance in statistical
and anatomically based personalized planning method by analysis.
using particular orthodontic (modified surgery-first model),
planning (full digital modality), and surgical (single-splint
Appendix A. Supplementary data
two-jaw procedure) approaches; hence, the generaliz-
ability of our findings to other settings of OGS care (e.g.,
Class II malocclusion or single-jaw surgery) cannot be Supplementary data to this article can be found online at
assumed. As the included patients were not selected based https://doi.org/10.1016/j.jfma.2021.05.014.
on surgical results (satisfactory or unsatisfactory), the bias
related to evaluations conducted only on the satisfactory References
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