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In Situ Bone Regeneration in Oral and Maxillofacial Surgery: Denition, Indications…
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H. S. H. Boroojeni et al.
Digitally Assisted Orthognathic Surgical
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Planning: Definition, History,
andInnovation
NouraM.AlOtaibi andAshrafF.Ayoub
1 Introduction
Orthognathic surgery allows three-dimensional (3D) movements of osteotomy segments of the maxilla, the mandible, the chin, and the associated soft tissue. The
impact of orthognathic surgery on facial appearance is signicant; therefore, precise
planning and accurate prediction are crucial prior to surgery. Recent advances in 3D
imaging technologies and the availability of software packages have improved
orthognathic predictionplanning, and the surgical outcomes.
Orthognathic workup composes several steps, which includes clinical assessment, diagnosis, model surgery, planning, prediction, and fabrication of surgical
guiding splint. The surgeon’s decision regarding the esthetic outcomes is fundamental in the treatment planning process regardless of the type of imaging, either twodimensional (2D) (traditional planning) or 3D (virtual planning). The 3D virtual
planning provides comprehensive details of facial morphologyfor the best surgical
management. Innovations in 3D imaging modalities, virtual surgical planning, and
CAD/CAM techniques have contributed to the improvement of the efciency, accuracy, and reproducibility of orthognathic surgery.
N. M. AlOtaibi
Oral and Maxillofacial Surgery, Glasgow University Dental Hospital and School, University
of Glasgow, Glasgow, UK
Department of Oral and Maxillofacial Surgery, King Saud University, Riyadh, Saudi Arabia
e-mail: Noura.Alotaibi@glasgow.ac.uk
A. F. Ayoub (*)
MVLS College, Dental school, University of Glasgow, Glasgow, UK
e-mail: Ashraf.Ayoub@glasgow.ac.uk
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
A. Khojasteh et al. (eds.), Emerging Technologies in Oral and Maxillofacial
Surgery, https://doi.org/10.1007/978-981-19-8602-4_10
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N. M. AlOtaibi and A. F. Ayoub
2 History ofPlanningOrthognathic Surgery
A successful surgical outcome of dentofacial deformities depends on orthognathic
planning and accurate prediction. Orthognathic model surgery planning is aimed to
simulate the surgical movement of the osteotomy segments and facilitate transferring the plan to the operation room. Therefore, the precision of the surgical workup
is mandatory to achieve the desired outcomes.
Traditional physical model surgery planning has been used for many decades to
simulate orthognathic movements. This includes a facebow transfer of the presurgical maxillary dental cast onto a semi-adjustable or orthognathicarticulators. The
facebow facilitates the transfer of the maxillary dentition in relation to the condylar
hinge axis of the temporomandibular joints to the articulator. Inaccuracy at this
stage can affect the intraoperative position of the maxilla, which will adversely
impact on the nal outcomes. There are several disadvantages of traditional model
surgery, including incorrect facebow transfers and inaccurate simulations of mandibular autorotation. Several methods have been developed to overcome the inaccuracies associated with facebow transfer and traditional model surgery [1–4]
(Fig.1). Recently, virtual orthognathic surgery planninghas replaced the traditional
articulator basedmodel surgery.
It has to be emphasized that both traditional and virtual orthognathic model surgery planning should be based on comprehensive clinical and radiographic examination. It is essential to record the accurate centric relation for both approaches,
mainly if “maxillary-rst” is selected for the surgical sequence in bimaxillary procedures. Innovations in 3D technologies and computer software have revolutionized
the prediction planning of orthognathic surgery. The advancesof 3Dimaging and
software technologies have facilitated the 3D virtual treatment planning, the
computer- assisted fabrication of surgical splints and the production ofcustomized
onlay-implants, cutting guides, and plates.
Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
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a
b
171
Fig. 1 Traditional physical model surgery (a) demonstration of inaccuracy in transferring the
occlusal plane usingconventional facebow (left side) and the accurateocclusal plane according to
the lateral cephalometric radiograph(right side), and (b) printingof 3D composite physical model
of the skull and dentation as an alternative method to overcome the limitaions of thearticulator, it
facilitates surgical planningand the prebendingof the xation plates. (Reprinted with permission
from [1])
3 Two-dimensionalOrthognathic SurgicalPlanning
The method is based on the prole prediction planning of the lateral cephalogram
radiographs. The clinician traces all points and measurements on the lateral cephalogrph. This method is time-consuming in addition to the inaccuracies of the measurements. Software based cephalometric analysis has provided an attractive
alternative to manual tracing. Various computer software packages were developed
to facilitatethe digitization of the cephalometriclandmarks and to obtainlinear and
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Fig. 2 Digitalized radiograph for cephalometric analysis
N. M. AlOtaibi and A. F. Ayoub
angular measurements automatically. This method simplies cephalometric analysis and saves time compared to the manual tracing of the radiographs (Fig.2). The
2D predictionplanning relies on a lateral cephalograph and a 1:1 ratio lateral transparent photograph of the patient’s prole that is directly superimposed on the radiographto produce a combined facial, skeletal, and dental image for analysis (Fig.3).
Several 2D softwarepackagesare available for the prediction of changes of the soft
tissue prole due to orthognathic movements. These packages arelimited to prole prediction planning which is of a limited value in the surgical correction of
facial asymmetry[5].
Figure 4 illustrates the Traditional orthognathic workup, the prediction planning should be based on comprehensive clinical assessment and radiographic
evaluation.
In summary, several potential errors are associated with traditional model surgery due to the inaccuracies in facebow transfer, bite registration, dental impressions, model measurements,and human errors related to each clinical and laboratory
step [6]. Studies on traditional 2D orthognathic planning using articulators and
cephalometric analysis have proved the signicant differences between the planned
and postoperative outcomes of orthognathic surgery [7].
Traditional Model Surgery
Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
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a
b
c
173
Fig. 3 Two-dimensional traditional orthognathic planning: (a) manual superimposition of lateral
cephalographon a 2D lateral photograph (1:1 ratio)followedby cutting and pasting of the osteotomy segments for proleprediction planning (b) 2D cephalometric analysis and orthognathic
prediction planning using a 2D softwarefor orthognathicprediction planning, (c) the limited2D
orthognathic prediction planning of the prolewhich is of a limited value in asymmetric cases
Dental Impressions
Facebow
Transfer
Fig. 4 The workow of traditional model surgery
Bite
Registration
Mounting of
dental models
on the articulator
Repositioning of
the osteotomy
segments
Rabrication of
the guiding
occlusal splint
174
Virtual Surgical Planning
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N. M. AlOtaibi and A. F. Ayoub
4 Three-dimensionalOrthognathic SurgicalPlanning
Virtual Surgical Planning (VSP)has been applied routinely in craniofacial surgery,
neurosurgery, and orthopedics [8–11]. The workow of 3D VSP for orthognathic
surgery is summarized in (Fig.5). VSPis usually delivered by the orthognathic
multidisciplinary team that consists of an oral and maxillofacial surgeon, orthodontist, and maxillofacial engineer/technologist. Some institutions have an ofcedbased 3D-VSP unit, and a VSP-trained maxillofacial engineer or technologist is
on-site.On the other hand,virtual meeting could be also carried outwith a third
party to conduct the VSPon-line.
Digitally assisted 3D virtual orthognathic planning has several advantages. It
improves accuracy and facilitates presurgical simulation. It provides a 3D assessment of the dentofacial components, jaws relationship, 3D cephalometry, a comprehensive visualization of the maxillomandibular complex, identication of
unrecognized yaw/pitch/roll movements, facial asymmetries, and changes of the
occlusal plane (Fig.6). Also, it allows immediate evaluation of the impact of the
surgical movements on facial hard and soft tissues that cannot be recognized by
+ +
12345
3D Data Acquisition
3D Composite Model Virtual Surgical
Osteotomies
3D Virtual Prediction Surgical Splint
Construction
Fig. 5 The workow of virtual surgical planning
Fig. 6 The 3D virtual model of the skin, jawbones, and dentitions of one of the facial asymme-
try cases
Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
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175
Fig. 7 Three-dimensional virtual orthognathic planning of correction of an anterior open bite
(AOB) showing the expected changes in facial appearance
traditional planning (Fig.7). Moreover, VSP eliminates all laboratory errors associated with traditional model surgery [7].It facilitates theimprovement of soft tissue,
whichis readily visible, predictable, and should be always considered in orthognathic surgicalplanning [12]. The trainees and patients can benet from virtual surgical planning as an educational tool.
Currently, none of the available 3D imaging modalities can accuratelycapture all
the structures of a the face 3 simultaneously which includes the facial skeleton,
dentition, and soft tissue. Therefore, combining and merging 3D imaging of different capture sources is often necessary (Fig.8).
4.1 Data Collection
4.1.1 Skull andJaw Bones
The bone structures of the skullcan be obtained by conventional computed tomography (CT) scan or cone beam computed tomography (CBCT) scan. Several advantages and disadvantages of each method have been reported. Today, CBCT isused
routinely for diagnosing and planning the surgical correction of dentofacial
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Fig. 8 Superimposition of stereophotogrammetry of the faceon a 3D CBCT scan using a matching algorithm to build the 3D virtual model for orthognathic planning
N. M. AlOtaibi and A. F. Ayoub
deformities. It is recommended to use a high-resolution CBCT scan for VSP at voxels size of a maximum of 0.3mm in height, width, and depth. The head scan is then
exported in Digital Imaging and Communications in Medicine (DICOM) formatfor
analysis and predictionplanning[13].
There are several advantages of CBCT over the conventional CT head scan that
include the position of the patient; in CT scanning, the patient is lying down, and the
soft tissues are affected by gravity. In contrast, the CBCT allows the face to be captured in the natural head position (NHP) while standing up or sitting down. Also, the
CT scanner encloses the patient’s head while the CBCT does not, which may pose
some difculties for claustrophobic patients. The CBCTscaning subject the patients
to a considerably less radiation dose compared to the conventional CT [14]. The
disadvantages of CBCT scanning includethe development of streak artifacts and
intensity noise from metallic objects, motion artifacts, and thenon-textured colorless skin capture.
4.1.2 Dentition
Due to the streak artifacts and magnication of the teeth in the CT/CBCT, the dentition must be replaced with an accurate 3D dentalimage [2, 15, 16]. The dentition
can be scanned and digitalized either directly or indirectly. The direct method of
capturing the dentition is achieved usingintraoral scanning (IOS) device. In the
indirect method thedental study modelsare scannedusinga laser scanner or a highresolution CT/CBCT of 0.2 voxel (see case 1).
CBCT Cast Scan
Currently, CBCT scans are used routinely for the scanning of dental study models
(Fig.9).
Intraoral Laser Scan (IOS)
The direct method of obtaining 3D data of thedentition is via intraoral scanners
(Fig.10) (see case 2). The main advantage of IOS is that it does not expose the
patients to radiationand eliminates the inconvenience of taking dental impression.
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