JC 10

Evaluation of a Fully Digital, In-House
Virtual Surgical Planning Workflow for

Bimaxillary Orthognathic Surgery
David Gagnier, Curtis Gregoire, James Brady, Andra Sterea and Taylor Chaput
Journal of Oral & Maxillofacial Surgery, 2024
Dr.B.SONIKA
2nd YR PG
ABSTRACT
Purpose: The purpose of this study was to evaluate the difference between the virtual surgical plan and actual surgical
outcome for orthognathic surgery using a fully digital, in-house VSP workflow.
Study Design, Setting, Sample: This is a prospective cohort study from September 2020 to November 2022 of patients
at the Victoria General Hospital in Halifax, NS, Canada who underwent bimaxillary orthognathic surgery. Patients were
excluded if they had previously undergone orthognathic surgery or were diagnosed with a craniofacial syndrome.
Main Outcome Variables: The primary outcome variables were the mean 3-dimensional (3D) (Euclidean) distance error,
as well as mean error and mean absolute error in the transverse (x axis), vertical (y axis), and anterior-posterior (z axis)
dimensions.
Covariates: Covariates included age, sex, and surgical sequence (mandible-first or maxilla-first).
Results: The study sample included 52 subjects (24 males and 28 females) with a mean age of 27.7 (12.1) years. Forty
three subjects underwent mandible-first surgery and 9 maxilla-first surgery. The mean absolute distance error was largest
in the anterior-posterior dimension for all landmarks (except posterior nasal spine, left condyle, and gonion) and exceeded
the threshold for clinical acceptability (2 mm) in 16 of 23 landmarks. Additionally, mean distance error in the anterior-
posterior dimension was negative for all landmarks, indicating deficient movement in that direction. The effect of surgical
sequence on 3D distance error was not statistically significant.
INTRODUCTION
• Orthognathic surgery is highly complex, and a meticulous surgical plan is
critical to its success.
• Virtual surgical planning (VSP) has modernized the process of surgical

planning and simulation for orthognathic surgery with the use of 3-
dimensional (3D) imaging, digital occlusal records, and specialized
planning software.
• VSP has also enabled the use of computer-aided design and

manufacturing of occlusal splints, patient-specific guides, and patient-
specific implants (PSIs) to more accurately reproduce the virtual plan in
the operating room.
AIM
• To measure the 3D distance error, as well as the mean error
and mean absolute error in the transverse, vertical, and
anterior-posterior dimensions, for a series of landmarks
between the virtual surgical plan and the actual surgical
outcome.
MATERIALS AND METHODS
STUDY DESIGN:
Prospective Cohort Study
INCLUSION CRITERIA:
• Patients requiring both maxillary and mandibular surgery (with or
without genioplasty), patients undergoing concurrent orthodontic
treatment with conventional fixed appliances.
• Patients undergoing concurrent orthodontic treatment with clear
aligner appliances.
EXCLUSION CRITERIA:
• Previously undergone orthognathic surgery or were diagnosed with a
craniofacial syndrome.
A Panoramic and Lateral Cephalometric radiograph, a CBCT image and a digital
impression using an intraoral scanner
All study subjects underwent LeFort I osteotomies and bilateral sagittal split
osteotomies. Some also underwent a genioplasty if indicated.
Both mandible-first and maxilla-first approaches were used, depending on

the virtual surgical plan.
LeFort I osteotomies were fixated at the level of the nasal aperture or wire
osteosynthesis at the zygomatic buttresses. Bilateral sagittal split osteotomies
were fixated with crescent-shaped 2.0 mm titanium plates.
The occlusal splint was removed at either 2 or 4 weeks and a postoperative CBCT
was obtained at the same appointment.
The 23 landmarks used to evaluate the
postoperative outcome
• Evaluation of the postoperative outcome involved
landmarking of the preoperative and postoperative volumes
using the same standardized protocol.
• The position of the landmarks in 3 dimensions was then

exported from both volumes in the form of x, y, and z
coordinates in millimeters.
• The difference between the postoperative and preoperative

landmarks was calculated giving the actual surgical
movements in the form of a linear distance in millimeters.
Voxel-based superimposition of the postoperative volume onto the
preoperative volume
RESULTS
• The study sample included 52 subjects (24 males and 28 females)
• Forty three subjects underwent mandible-first surgery and nine maxilla-first

surgery.
• The mean absolute distance error was largest in the anterior-posterior dimension
for all landmarks (except posterior nasal spine, left condyle, and gonion) and
exceeded the threshold for clinical acceptability (2 mm) in 16 of 23 landmarks.
• Additionally, mean distance error in the anterior-posterior dimension was negative

for all landmarks, indicating deficient movement in that direction.
• The effect of surgical sequence on 3D distance error was not statistically

significant
DISCUSSION
• The investigators hypothesized that this protocol could provide a mean
absolute error of less than 2 mm, a commonly used threshold for clinical
acceptability
• In the present study, many of the landmarks fell just outside this range,
primarily due to an increased error in the anterior-posterior dimension
• With splint-based surgery, there is no guide for the vertical position of the
maxilla. Any deviation from the intended vertical position will cause an
unplanned autorotation of the maxillomandibular complex, influencing the
final anterior-posterior position.
CONCLUSION
• In general, the largest contributor to mean 3D distance error was
deficient movement in the anterior-posterior direction.
• Otherwise, mean absolute distance error in the vertical and

transverse dimensions was clinically acceptable (< 2 mm).
• These findings were felt to be valuable for treatment planning

purposes when using a fully digital, in-house VSP workflow.
REFERENCE
• Schneider D, Kammerer PW,
Hennig M, Schon G, Thiem DGE,
Bschorer R. Customized virtual
surgical planning in bimaxillary
orthognathic surgery: A prospective
randomized trial. Clin Oral Investig
23(7):3115–3122, 2019
CROSS REFERENCES
• Xi T, van Luijn R, Baan F, et
al. Landmark-based versus
voxelbased 3-dimensional
quantitative analysis of
bimaxillary osteotomies: A
comparative study. J Oral
Maxillofac Surg
78(3):468.e1– 468.e10,
2020
THANK YOU

JC 10

Uploaded by

Copyright:

Available Formats

JC 10

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

JC 10

Uploaded by

Copyright:

Available Formats

Evaluation of a Fully Digital, In-House

Virtual Surgical Planning Workflow for

• Virtual surgical planning (VSP) has modernized the process of surgical

• VSP has also enabled the use of computer-aided design and

Both mandible-first and maxilla-first approaches were used, depending on

• The position of the landmarks in 3 dimensions was then

• The difference between the postoperative and preoperative

• Forty three subjects underwent mandible-first surgery and nine maxilla-first

• Additionally, mean distance error in the anterior-posterior dimension was negative

• The effect of surgical sequence on 3D distance error was not statistically

• Otherwise, mean absolute distance error in the vertical and

• These findings were felt to be valuable for treatment planning

You might also like