Orthognathic Surgery Treatment Research Articles

Artificial intelligence as a prediction tool for orthognathic surgery assessment.

An ideal orthodontic treatment involves qualitative and quantitative measurements of dental and skeletal components to evaluate patients' discrepancies, such as facial, occlusal, and functional characteristics. Deciding between orthodontics and orthognathic surgery remains challenging, especially in borderline patients. Advances in technology are aiding clinical decisions in orthodontics. The increasing availability of data and the era of big data enable the use of artificial intelligence to guide clinicians' diagnoses. This study aims to test the capacity of different machine learning (ML) models to predict whether orthognathic surgery or orthodontics treatment is required, using soft and hard tissue cephalometric values. A total of 920 lateral radiographs from patients previously treated with either conventional orthodontics or in combination with orthognathic surgery were used, comprising n = 558 Class II and n = 362 Class III patients, respectively. Thirty-two measures were obtained from each cephalogram at the initial appointment. The subjects were randomly divided into training (n = 552), validation (n = 183), and test (n = 185) datasets, both as an entire sample and divided into Class II and Class III sub-groups. The extracted data were evaluated using 10 machine learning models and by a four-expert panel consisting of orthodontists (n = 2) and surgeons (n = 2). The combined prediction of 10 models showed top-ranked performance in the testing dataset for accuracy, F1-score, and AUC (entire sample: 0.707, 0.706, 0.791; Class II: 0.759, 0.758, 0.824; Class III: 0.822, 0.807, 0.89). The proposed combined 10 ML approach model accurately predicted the need for orthognathic surgery, showing better performance in Class III patients.

Osteotomy Le fort I as a Treatment option for class III Dentoskeletal Problem

Introduction: Orthognathic surgery is surgery to correct the jaw relation and which aim to correct dentoskeletal deformities and a treatment option for severe deformity that cannot be corrected by orthodontic treatment alone. Le fort I osteotomy is a technique in orthognathic surgery that aims to correct the maxilla. In its management, it is possible for correction of the maxilla and mandible to achieve an optimal jaw relation, function and esthetics. Case report: This case report explained a patient with maxilla retrognathism accompanied by function and aesthetic problems. This patient was diagnosed with class III dysgnathy and was performed orthognathic surgery treatment with le fort I osteotomy technique under general anesthesia at Central Operating Theater at Hasan Sadikin General Hospital, Bandung, and was evaluate periodically after the surgery. Conclusion: In this case, the patient's function and aesthetic problems was corrected without causing any postoperative complications. Careful planning with a good calculation and treatment plans are important for obtaining a good result. Keywords: Le fort I osteotomy, class III disgnathy, dentoskeletal deformity

A Comparative Analysis of Artificial Intelligence and Manual Methods for Three-Dimensional Anatomical Landmark Identification in Dentofacial Treatment Planning.

With the growing demand for orthognathic surgery and other facial treatments, the accurate identification of anatomical landmarks has become crucial. Recent advancements have shifted towards using three-dimensional radiologic analysis instead of traditional two-dimensional methods, as it allows for more precise treatment planning, primarily relying on direct identification by clinicians. However, manual tracing can be time-consuming, mainly when dealing with a large number of patients. This study compared the accuracy and reliability of identifying anatomical landmarks using artificial intelligence (AI) and manual identification. Thirty patients over 19 years old who underwent pre-orthodontic and orthognathic surgery treatment and had pre-orthodontic three-dimensional radiologic scans were selected. Thirteen anatomical indicators were identified using both AI and manual methods. The landmarks were identified by AI and four experienced clinicians, and multiple ANOVA was performed to analyze the results. The study results revealed minimal significant differences between AI and manual tracing, with a maximum deviation of less than 2.83 mm. This indicates that utilizing AI to identify anatomical landmarks can be a reliable method in planning orthognathic surgery. Our findings suggest that using AI for anatomical landmark identification can enhance treatment accuracy and reliability, ultimately benefiting clinicians and patients.

The accuracy and reliability of different midsagittal planes in the symmetry assessment using cone-beam computed tomography.

Symmetry is an essential component of esthetic assessment. Accurate assessment of facial symmetry is critical to the treatment plan of orthognathic surgery and orthodontic treatment. However, there is no internationally accepted midsagittal plane (MSP) for orthodontists and orthognathic surgeons. The purpose of this study was to explore a clinically friendly MSP, which is more accurate and reliable than what is commonly used in symmetry assessment. Forty patients with symmetric craniofacial structures were analyzed on cone-beam computed tomography (CBCT) scans. The CBCT data were exported to the Simplant Pro software to build four reference planes that were constructed by nasion (N), basion (Ba), sella (S), odontoid (Dent), or incisive foramen (IF). A total of 31 landmarks were located to determine which reference plane is the most optimal MSP by comparing the asymmetry index (AI). The mean value of AI showed a significant difference (p < 0.05) among four reference planes. Also, the mean value of AI for all landmarks showed that Plane 2 (consisting of N, Ba, and IF) and Plane 4 (consisting of N, IF, and Dent) were more accurate and stable. In conclusion, the MSP consisting of N, Dent, and IF shows more accuracy and reliability than the other planes. Further, it is more clinically friendly because of its significant advantage in landmarking.

Perceived Effects of Orthognathic Surgery versus Orthodontic Camouflage Treatment of Convex Facial Profile Patients.

Increased facial profile convexity has a common occurrence in the population and is a primary reason for seeking orthodontic treatment. The present study aimed to compare the perceived changes in facial profile appearance between patients treated with combined orthognathic/orthodontic treatment versus only orthodontic camouflage treatment. For this reason, 18 pairs of before- and after-treatment facial profile photos per treatment group (n = 36 patients) were presented to four types of assessors (surgeons, orthodontists, patients, laypeople). Ratings were recorded on 100 mm visual analogue scales depicted in previously validated questionnaires. All rater groups identified minor positive changes in the facial profile appearance after exclusively orthodontic treatment, in contrast to substantial positive changes (14% to 18%) following combined orthodontic and orthognathic surgery. The differences between the two treatment approaches were slightly larger in the lower face and the chin than in the lips. The combined orthodontic and orthognathic surgery interventions were efficient in improving the facial appearance of patients with convex profile, whereas orthodontic treatment alone was not. Given the significant influence of facial aesthetics on various life aspects and its pivotal role in treatment demand and patient satisfaction, healthcare providers should take these findings into account when consulting adult patients with a convex facial profile.

¿Qué papel tiene la ortodoncia en el tratamiento de cirugía ortognática?

Introduction: In orthognathic surgery treatment, orthodontics plays a fundamental role. By improving the inclination of the maxillary and mandibular incisors, as well as correcting bilateral posterior crossbite, it contributes significantly to the correction of facial and dental problems. Objective: To inform patients and the general population what the function of orthodontics is within orthognathic surgery. Design: Systematic review of studies published from 1998 to 2021. Data sources: PubMed. Study selection: A reviewer searched, selected and extracted information from the articles that were selected. All pooled articles were based on random effects models. Results: After collecting this information we can give results. Orthodontics helps in many factors in the process of orthognathic surgery to achieve an aesthetic result, orthodontics within orthognathic surgery fulfills the function of aligning the maxillary and mandibular dental arches; corrects crossbite; treats dentofacial deformities; achieves facial harmonization.

Modification of surgical and positioning splint for orthognathic surgical treatment of facial asymmetry

Present short communication demonstrates innovative approach for surgical and positioning splint modification, which could improve accuracy of orthognathic surgery during facial asymmetry treatment. Usage of traditionally designed splint leads to the orientation of the midline based just on visual control, which inevitably associated with some level of maxilla deviation. It was proposed to design splint with mutually perpendicular planes in its’ frontal part at the specialized software. Such approach helps to align vertical plane of the splint with the midline vertical facial plane, while horizontal component could be aligned with the horizontal one accordingly. Proposed approach was approbated in five different clinical cases of facial asymmetry treated by orthognathic surgery. In all analyzed cases dental midline aligned perfectly with the planned one, in two cases the midline sagittal plane deviations (from ANS to PNS) resulted to be less than 2°. The horizontal occlusal plane deviations were considered clinically non-significant. Modification of the surgical splint for jaws positioning in orthognathic surgery treatment enables possibilities to check and control position of maxilla regarding reference facial planes intraoperatively, which in turn increases the accuracy of bone fragments placement and assure high precision of orthognathic surgery for asymmetric cases.

Can Condylectomy Alone Achieve Facial Symmetry in Patients With Hemimandibular Hyperplasia (Condylar Hyperplasia Type 2)?

The purpose of the present study was to evaluate the 3-dimensional orofacial changes occurring after proportional condylectomy in patients with unilateral condylar hyperplasia type 2 (hemimandibular hyperplasia). Eight patients underwent proportional condylectomy that was not followed by orthognathic surgery or orthodontic treatment for at least 1 year. The precondylectomy and postcondylectomy photographs and radiographs were analyzed cephalometrically and compared. The average length of the condylar segment removed was 13mm and this resulted in almost equal heights of the ramus-condyle units of both sides. Evaluations in the vertical plane improved after surgery; however, when the preoperative asymmetry was significant, the residual asymmetry continued to be notable after condylectomy. Transverse plane evaluations improved after condylectomy, and chin position was satisfactorily centralized in all patients. In the horizontal plane, mandibular setback occurred, and this was considered favorable when the preoperative skeletal profile was class III, whereas the opposite was when the patient was class I before surgery. The occlusion improved gradually over the postoperative months by the intrusion on the affected side and extrusion on the unaffected side into a bilaterally balanced posterior contacts with residual anterior open bite. In conclusion, condylar hyperplasia type 2 patients with mild asymmetry and low esthetic demands can benefit from proportional condylectomy as the sole treatment to both stop the hyperplastic condylar growth and improve the asymmetry to some extent. Surgeons should be able to predict the change that is expected to occur after proportional condylectomy and discuss this with the patient before surgery.

Association of Body Mass Index (BMI) with Lip Morphology Characteristics: A Cross-Sectional Study Based on Chinese Population

Lip morphology is essential in diagnosis and treatment of orthodontics and orthognathic surgery to ensure facial aesthetics. Body mass index (BMI) has proved to have influence on facial soft tissue thickness, but its relationship with lip morphology is unclear. This study aimed to evaluate the association between BMI and lip morphology characteristics (LMCs) and thus provide information for personalized treatment. A cross-sectional study consisted of 1185 patients from 1 January 2010 to 31 December 2020 was conducted. Confounders of demography, dental features, skeletal parameters and LMCs were adjusted by multivariable linear regression to identify the association between BMI and LMCs. Group differences were evaluated with two-samples t-test and one-way ANOVA test. Mediation analysis was used for indirect effects assessment. After adjusting for confounders, BMI is independently associated with upper lip length (0.039, [0.002-0.075]), soft pogonion thickness (0.120, [0.073-0.168]), inferior sulcus depth (0.040, [0.018-0.063]), lower lip length (0.208, [0.139-0.276]), and curve fitting revealed non-linearity to BMI in obese patients. Mediation analysis found BMI was associated with superior sulcus depth and basic upper lip thickness through upper lip length. BMI is positively associated with LMCs, except for nasolabial angle as negatively, while obese patients reverse or weaken these associations.

Pediatric Insurance Coverage Variation of Orthognathic Surgery and Orthodontic Treatment for Congenital Craniofacial Abnormalities

Introduction: Orthognathic surgery and associated orthodontic treatment are necessary parts of care for children who have congenital craniofacial deformities. Inconsistencies in insurance coverage across the U.S. have led to serious barriers to care for many families. In an effort to describe common patterns of coverage, we report craniofacial coverage criteria for both medical and dental insurances. Methods: In this study, we analyzed medical policies of the top 50 market share insurance providers, as well as all dental policies available in the U.S., for a total of 776 policies. Included in this analysis are Medicaid and Children’s Health Insurance Program (CHIP). Results: A total of 94.1% of both private medical and dental policies provide up-front limited coverage of congenital-related treatments, along with 98.0% of Medicaid plans covering oral surgery for cleft palate. Almost all states (n = 47) offered at least one private medical plan that covered orthognathic surgery for congenital and craniofacial anomalies, while n = 3 states (Colorado, Ohio, West Virginia) did not offer any. Coverage for oral surgery and orthodontic treatment by private dental and standalone dental plans were consistent, with 80.9% (n = 518) plans offering (52 ± 14)% in-network coverage of costs for oral surgery and 55.6% (n = 356) offering a similar (49 ± 12)% out-of-network coverage. Forty-six Medicaid and 44 CHIP programs offered coverage of “oral surgery for cleft palate.” Of these plans, 8.8% (n = 9) covered oral surgery as a medical benefit and 2.9% (n = 3) required that the surgery be “medically necessary.” Fifty Medicaid and 48 CHIP plans offered coverage for orthodontia. Conclusion: Many systemic barriers remain in the way of consistent access to affordable care in the United States. Coverage for patients with congenital anomalies remains highly variable and greater efforts are needed to ensure consistent, comprehensive coverage.

SKELETAL CLASS III UPPER BILATERAL CANINE ECTOPIA AND NANIC LATERAL INCISORS – A CAMOUFLAGE APPROACH

Skeletal class III patients, especially adults, are best treated by orthognathic surgery and orthodontic treatment; when adding anunfavorable factor such as upper nanic incisors, the treatment difficulty increases. In this particular case, the patient and both his parentsrejected the orthognathic surgery, their main concern being the crowding of the teeth and not the physical appearance of the facialprofile. Based on the skeletal measurements, the orthodontic treatment goals were: align both arches, retrude lower arch, stabilizationof occlusion. MBT classic brackets were bonded aiming for closure of spaces in the lower arch and retrusion of lower incisors. Afterthe active treatment, 16 months, essix retainers were given to wear 12/24. The patient was instructed to be aware of any change in hisocclusion and call the clinic for any small tooth movement immediately.

Comparison of Occlusal Digital Analysis Using T-Scan in Orthognathic Surgery with Only Conventional Orthodontic Patients.

The aims of this study were to compare the changes in occlusal parameters, TMJ status clinically in patients after the completion of orthognathic surgery, and patients undergoing only orthodontic treatment and with patients having normal occlusion, using T-Scan. This prospective controlled clinical trial, consisting of three groups with a sample size of twelve. Group 1 consisted of patients who underwent orthognathic surgery and orthodontic treatment. Group 2 consists of patients who underwent only orthodontic treatment (camouflage). Clinical examination of the patient (TMJ and Occlusal status) and T-Scan was performed at the time of debonding of the orthodontic brackets, 6months and 1-year after first evaluation for group 1 and 2 patients. The collected data between groups are compared and interpreted. The statistical analysis was performed using STATA/IC version 16.1 statistical software. Intragroup comparison for the study variables occlusion time, disocclusion time and maximum bite force between different time periods (T1, T2, T3) for all the three intervention groups using repeated measures. Hypothesis testing for maximum bite force, occlusion time and disocclusion time in orthognathic group (Group 1) as compared to orthodontic group (Group 2) for three different time periods using repeated measures ANOVA and Bonferroni test showed P value < 0.05 which is statistically significant. In conclusion, evaluation of occlusion using T-Scan give us an insight of the discrepancies in occlusion which is useful during pre-operative planning and especially in the post-operative follow-up period during the retention phase. Examination of TMJ in these patients at various intervals is necessary as any minor occlusal disturbances may lead to TMJ disorders.

Face comparison analysis of patients with orthognathic surgery treatment using cloud computing–based face recognition application programming interfaces

This study aimed to investigate whether the postoperative change in patients after orthognathic surgery, whose facial aesthetics was affected, led to detectable differences using Microsoft Azure, Amazon Web Services Rekognition, and Face++, which were commercially available face recognition systems. Photographs of 35 patients after orthognathic surgery were analyzed using 3 well-known cloud computing-based facial recognition application programming interfaces to compute similarity scores between preoperative and postoperative photographs. The preoperative, relaxed, smiling, profile, and semiprofile photographs of the patients were compared separately to validate the relevant application programming interfaces. Patient characteristics and type of surgery were recorded for statistical analysis. Kruskal-Wallis rank sum tests were performed to analyze the relationship between patient characteristics and similarity scores. Multiple-comparison Wilcoxon rank sum tests were performed on the statistically significant characteristics. The similarity scores in the Face++ program were lower than those in the Microsoft Azure and Amazon Web Services Rekognition. In addition, the similarity scores were higher in smiling photographs. A statistically significant difference was found in similarity scores between relaxed and smiling photographs according to different programs (P<0.05). For all 3 facial recognition programs, comparable similarity scores were found in all photographs taken before and after surgery across sex, type of surgery, and type of surgical approach. The type of surgery and surgical approach, sex, and amount of surgical movement did not significantly affect similarity scores in any facial recognition programs (P>0.05). The similarity scores between the photographs before and after orthognathic surgery were high, suggesting that the software algorithms might value measurements on the basis of upper-face landmarks more than lower-face measurements.

Eye-tracking system-based evaluation of orthodontists’ and patients’ visual attention to facial features before and after orthognathic surgery treatment

This research aims to determine the differences between the patient and orthodontist in terms of their visual attention using an eye-tracking system-based evaluation system for assessing facial features before and post orthognathic surgery. The participants included patients who underwent orthognathic treatment （n＝26; mean age, 26.04±6.6 years） at the Showa University Dental Hospital and orthodontists with ≥5 years of experience at our department （n＝10, mean age, 31.4±2.2 years）. Visual attention was assessed using an eyeglass-type device （eye tracker）. Facial photographs of each patient, both frontal and side views, were shown on a monitor to the patients and orthodontists, and their respective visual attention was comparatively assessed. SPSS Statistics 25 was used for the study data statistical analysis. The results were contrasted between the patients and the orthodontists using a linear mixed model, with photographs labeled with the same number serving as repeat factors. Total fixation analysis demonstrated that patients focused more on the lower face postoperatively （P＝0.044）, while orthodontists focused more on the entire face both postoperative and preoperatively. The postoperative findings also demonstrated significant differences in many areas. There was a significant difference in how orthodontists and patients examined the face. This study found differences in visual attention between patients and orthodontists when they examined facial features before and after orthognathic surgery.

Rehabilitation with orthognathic surgery and orthodontic treatment in patient with severe occlusal disharmony: A case report

Rehabilitation with orthognathic surgery and orthodontic treatment in patient with severe occlusal disharmony: A case report

Quality of Life Changes in Taiwanese Patients with Dentofacial Deformities Undergoing Orthognathic Surgery

Objectives: The evaluation of orthognathic surgery (OgS) is shifting towards a coherent approach for patient care that balances objective clinician-defined measures with patient-centred outcome assessments, including health-related quality of life (QoL). This aim of this study adds to the pool of literature in East Asian subjects by studying the longitudinal QoL changes in Taiwanese patients with dentofacial deformities (DFD) undergoing OgS, using two standardized questionnaires at three different treatment stages. Materials and Methods: This prospective cohort study comprised 113 consecutive Taiwanese OgS patients who underwent surgical-orthodontic treatment between 2015 and 2018. The subjects completed SF-36 and OHIP-14 standardized questionnaires with one additional aesthetics question at one month before OGS (T1), 3 months (T2) and at debond (T3). All responses were screened, and 90 valid questionnaires included for analysis. Additional subgroup comparisons were made between Class II and Class III patients, symmetric and asymmetric patients, surgery-first approach and orthodontics-first approach, presence or absence of genioplasty, genders, and younger and older patients. Results: The cohort was comprised largely of skeletal Class III patients (84.4%) and showed significant improvements in OHIP-14 and Aesthetic score from T1 to T3. Pre-surgical orthodontic decompensation leads to a decrease in QoL. Patients who have undergone genioplasty have better generic health QoL than those without genioplasty at T3. Male DFD patients have better generic oral health and aesthetics QoL than female DFD patients. Age does not appear to affect generic health, generic oral health and aesthetics QoL at any time during OgS treatment. Conclusion: OgS has positive effects on generic health, generic oral health and aesthetics QoL in DFD patients. The effect of asymmetry on QoL in OgS patients remains an area that requires further research in order to clarify conflicting results in the literature. Future studies should explore the long-term stability of QoL effects.

Correction of malocclusion in individuals with osteogenesis imperfecta: a systematic review

The aim of the study was to verify the viability of the correction of malocclusion in individuals with osteogenesis imperfecta (OI). A systematic review was developed using PubMed, Web of Science, Scopus, Lilacs, Ovid, Google Scholar and OpenGrey databases. The review was registered in PROSPERO (CRD42018114217). Data extraction was conducted by two researchers. Studies describing orthodontic treatment, orthognathic surgery or orthodontic treatment combined with orthognathic surgery for the correction of malocclusion in individuals with OI were eligible. The methodological quality of the articles was appraised using the case report assessment tool proposed by the Joanna Briggs Institute. The results were synthesized qualitatively. The 22 case reports included in the present review involved a total of 28 clinical cases. Malocclusion was considered severe in 11 cases, with records of negative overjet between nine and 26mm. Orthodontic treatment was performed in four cases, orthognathic surgery was performed in five cases and orthodontic treatment combined with orthognathic surgery was performed in 19 cases. All treated cases had favorable clinical results. Overall, the methodological quality of the articles included was satisfactory. Based on the analyzed cases, which reported only cases with successful results, treatment for malocclusion is viable in individuals with OI. When duly indicated, treatment can be performed with orthodontic treatment, orthognathic surgery or a combination of both, providing satisfactory esthetic and functional results with adequate stability.

Anterior Tooth Size Discrepancy in Class III Surgical Patients.

The purpose of the present study was to specify whether there are mesiodistal tooth size discrepancies in the anterior region in patients with dentoskeletal Class III malocclusion who underwent orthognathic surgery and orthodontic treatment and to assess the relationship between anterior Bolton ratio and dentoskeletal cephalometric measurements. The diagnostic dental casts and lateral cephalometric radiographs of 113 nongrowing patients (54 females and 59 males; mean age: 19.96 ± 4.42 years) with dentoskeletal Class III malocclusion who underwent orthognathic surgery and orthodontic treatment were included in the study. The mesiodistal widths of the 6 anterior teeth were measured from dental casts using a digital caliper accurate to 0.01 mm and anterior Bolton ratios were calculated. Lateral cephalograms were digitalized and used to measure 4 skeletal and 4 dental parameters. The mean anterior ratio of Class III surgical patients was 80.1% with a standard deviation of 2.8%. Clinically significant anterior tooth size discrepancies (greater than ±2 standard deviation) were found in 40.7% of the sample, 97.8% of those patients having anterior mandibular tooth excess. No significant correlation was found between the anterior Bolton ratio and cephalometric measurements. Clinicians should consider the probability of tooth size discrepancy in the diagnosis and treatment planning of Class III surgical patients and should perform interventions to eliminate these discrepancies during presurgical orthodontic treatment.

Le Fort I Osteotomy Complicated by Presence of Maxillary Sinus Septa.

Presence of maxillary sinus septa, an anatomical variant, has never been documented as a possible complication of Le Fort I orthognathic surgery procedure. This case report describes the difficulty faced by an experienced surgeon during Le Fort I down-fracture procedure. The osteotomized maxilla remained firm despite confirmation that all osteotomy cuts have been performed adequately. The presence of a bilateral sagittally oriented maxillary sinus septa extending from the floor to the roof of the sinus in this case had prevented separation of the lower maxilla during down-fracture maneuver. Such normal anatomical variant must be identified during orthognathic surgery treatment planning session to avoid grave complications.

How readable are orthognathic surgery consent forms?

The valid consent process for medical intervention requires the disclosure of information in a format that is easily understandable by the patient. The aim of this investigation was to assess the readability of orthognathic surgery informed consent forms (OSICFs). An online search methodology was conducted to identify OSICFs for analysis. The forms that satisfied inclusion/exclusion criteria were evaluated according to a standardised protocol. The readability of the content was assessed using three validated tools: the Simple Measure of Gobbledegook (SMOG) score, Flesch-Kincaid Grade-Level (FKGL) score and Flesch Reading Ease (FRE) score. Most of the 26 evaluated OSICFs were sourced from websites within the United States (69.2%) and from oral and maxillo-facial surgery practices (76.9%). Two of the assessed forms were template OSICFs available from oral and maxillo-facial professional societies to its members. The scores from the three tools found that the content of 84.6% to 92.3% of the forms were "difficult" to read. The mean (SD) SMOG score for all evaluated OSICFs was 12.31(2.22) [95% CI: 11.42 to 13.21]. The SMOG and FKGL scores were closely correlated (r=0.99, P<0.0001; 95% CI: 0.9864 to 0.9973). There was no association between SMOG scores and the number of words contained within each consent form (r=-0.047;95% CI: -0.44 to 0.36). The OSICFs surveyed in this investigation failed to meet recommended readability levels. A significant number of patients are not likely to understand the information contained within the forms. Orthodontists are advised that poor literacy skills of their patients may preclude them from validly consenting to orthognathic surgery treatment procedures.