Artificial intelligence (AI) continues to enhance surgical care, with growing applications in craniofacial surgery, including automated cephalometric analysis, diagnostics for craniosynostosis, virtual surgical planning, perioperative decision support, and prediction of postoperative outcomes. As these technologies transition from experimental systems to clinical tools that influence diagnosis, planning, and counseling, the specialty faces increasingly complex ethical and regulatory challenges. In this manuscript, the authors review and synthesize the ethical principles guiding the responsible adoption of AI in craniofacial surgery, including informed consent in predominantly pediatric populations, the risks of algorithmic bias, the heightened privacy concerns associated with facial biometrics, the requirements for transparency and explainability, and the evolving concepts of clinician accountability in AI-augmented decision-making. The authors also examine the global regulatory landscape, focusing on the US FDA's framework for AI/ML-based software as a medical device (SaMD), the European Union's medical device and AI regulations, and international oversight models. The implications of continuous-learning systems for real-world performance monitoring and postmarket governance are discussed in detail. Finally, the authors propose a pragmatic implementation framework emphasizing governance structures, pilot evaluation, structured local validation, performance auditing, and equity-centered deployment. Establishing rigorous ethical guardrails, robust regulatory pathways, and specialty-specific governance structures will be essential for realizing AI's potential while safeguarding patient trust, safety, and equity in craniofacial care.

Background: Reconstruction of the maxilla and midface remains one of the most demanding challenges in craniofacial surgery, requiring precise planning and a clear understanding of defect geometry to achieve functional and esthetic restoration. Advances in computer-assisted surgery (CAS) and virtual surgical planning (VSP), based on 3D segmentation of radiologic imaging, have significantly improved the management of maxillary deformities, allowing for further knowledge of patient-specific information, including anatomy, pathology, surgical planning, and reconstructive issues. The integration of computer-aided design and manufacturing (CAD/CAM) and 3D printing has further transformed reconstruction through customized titanium meshes, implants, and surgical guides. Methods:This systematic review, conducted following PRISMA 2020 guidelines, synthesizes evidence from clinical studies on CAD/CAM-assisted reconstruction of maxillary and midfacial defects of congenital, acquired, or post-resection origin. It highlights the advantages and drawbacks of maxillary reconstruction with patient-specific implants (PSISs). Primary outcomes are represented by accuracy in VSP reproduction, while secondary outcomes included esthetic results, functions, and assessment of complications. Results: Of the 44 identified articles, 10 met inclusion criteria with a time frame from April 2013 to July 2022. The outcomes of 24 treated patients are reported. CAD/CAM-guided techniques seemed to improve osteotomy accuracy, flap contouring, and implant adaptation. Conclusions: Although current data support the efficacy and safety of CAD/CAM-based approaches, limitations persist, including high costs, technological dependency, and variable long-term outcome data. This article critically evaluates the role of PSISs in maxillofacial reconstruction and outlines future directions for its standardization and broader adoption in clinical practice.

Craniofacial procedures such as fronto-orbital remodelling can result in forehead contour irregularities and bitemporal hollowing many years following the initial surgery. Hydroxyapatite cement (HAC) cranioplasty is a secondary surgical procedure that can be used to recontour the forehead and superior orbital rim. This approach relies on the surgeon's subjective assessment of form and aesthetics both preoperatively and intraoperatively. The highly artistic nature of this procedure means that outcomes, although often good, can be inconsistent and may result in undercorrection or overcorrection. The following case report describes a 14-year-old female who underwent HAC onlay cranioplasty to correct forehead asymmetry, irregular contours and supraorbital retrusion following bifronto-orbital advancement surgery for unicoronal synostosis. This is the first case described where virtual surgical planning (VSP) with 3D printed patient-specific guides was used to reduce the highly subjective nature of onlay cranioplasty and increase precision, efficacy, consistency of results and aesthetic outcome.

The success of virtual surgical planning (VSP) in bimaxillary orthognathic surgery relies on the precise translation of digital plans into operative outcomes. Although computer-assisted design and 3D-printed surgical guides are increasingly adopted to improve surgical accuracy, clinical data on the performance of systems employing Mimics software-particularly concerning long-term postoperative stability-remain scarce. Twelve consecutive patients undergoing bimaxillary surgery between July 2023 and September 2024 were prospectively enrolled. Preoperative cone-beam computed tomography (CBCT) and dental models were integrated into Mimics software for multimodal registration, 3D reconstruction, and VSP. Surgical procedures included Le Fort I osteotomy, bilateral sagittal split osteotomy (BSSO), and genioplasty. A fully customized 3D-printed surgical guide system, including osteotomy guides, repositioning guides, and occlusal splints was employed. Postoperative CBCT scans were acquired at 10days (T1), 1month (T2), 3months (T3), and 6months (T4). CBCT scans from T1 and T4 were analyzed in 3-Matic to quantify 3D deviation. Clinical success was defined as linear deviations ≤ 1.5mm and angular deviations ≤ 2°. Longitudinal comparisons of CBCT datasets across all postoperative intervals (T1-T4) were performed to assess stability. Statistical analysis was conducted using paired t-tests in SPSS 26.0 (α= 0.05). Mean linear deviation was 1.34 ± 0.28mm at T1 and 1.17 ± 0.22mm at T4, while angular deviation was 1.95° ± 0.41°and 1.81° ± 0.35°, respectively. All values were within the predefined clinical thresholds. Maxillary landmarks (ANS, A-point, dental cusps) remained stable throughout the observation period (P > 0.05), whereas mandibular landmarks (B-point, pogonion, menton, dental cusps) demonstrated statistically significant progressive stabilization (P < 0.05). Directional analysis revealed the highest accuracy in the horizontal plane (0.58 ± 0.16mm) and the greatest deviations in the sagittal direction (1.71 ± 0.61mm at T4). The 3D-printed digital guide system achieved clinically acceptable accuracy and demonstrated favorable postoperative stability. Maxillary skeletal landmarks exhibited superior precision compared to dental references. Notably, mandibular structures showed significant positional improvement over time, suggesting distinct healing dynamics between the jaws. All observed deviations fell within published tolerances, validating the system's reliability for clinical application in orthognathic surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orthognathic surgery is widely used to correct dentofacial deformities. Recent advancements in virtual surgical planning have enhanced the precision of these procedures. However, ensuring the surgical outcome reflects the virtual plan remains a challenge. This study aims to compare surgical accuracy and cost-efficiency between standard miniplates and patient-specific implants, using intraoperative computed tomography and 3D superposition. A total of 90 patients were included: 75 retrospective controls treated with standard implants and 15 prospective patients treated with patient-specific implants. Surgeries included Le Fort I, BSSO, and genioplasty. Intraoperative computed tomography scans were acquired and superposed with virtual plans to assess 3D accuracy. Statistical comparisons were made using the Mann-Whitney U test. The patient-specific implant group demonstrated significantly improved surgical accuracy in maxillary midline, mandibular midline, maxillary dental plane, and pogonion (p<0.05). One patient with patient-specific implant required intraoperative replacement of mandibular plates due to condylar repositioning. Cost analysis revealed higher costs for PSI cases compared to standard, with no significant difference in surgical time. While patient-specific implants offer benefits in standardization and intraoperative precision, their higher cost and reduced adaptability in the mandible limit their application. Future studies should explore hybrid approaches and broader cost-efficiency analysis.

Objective: The objective of this study is to synthesize and critically appraise how artificial intelligence (AI) is being integrated into oral and maxillofacial surgery (OMFS). This review’s novel contribution is to jointly map clinical applications (diagnostics, virtual surgical planning, intraoperative guidance) and operational uses (triage, scheduling, documentation, patient communication), quantifying evidence and validation status to provide practice-oriented guidance for adoption. Study Design: A narrative review of the recent literature and expert analysis, supplemented by illustrative multicenter implementation data from OMFS practice, was carried out. Results: AI demonstrates high performance in radiographic analysis and virtual planning (up to 96% predictive accuracy and sub-millimeter soft-tissue simulation error), with clinical reports of shorter planning times and more efficient patient communication. Early deployments in OMFS clinics have increased appointment bookings, while maintaining high patient satisfaction, and reduced the administrative burden. Remaining challenges include data quality, explainability, and limited multicenter and pediatric validation, which constrain generalizability and require clinician oversight. Conclusions: AI offers substantive benefits across the OMFS care continuum—improving diagnostic accuracy, surgical planning, and patient engagement while streamlining workflows. Responsible adoption depends on transparent validation, data governance, and targeted training, with attention to cost-effectiveness. Immediate priorities include standardized reporting of quantitative outcomes (e.g., sensitivity, specificity, time saved) and prospective multicenter studies, ensuring that AI augments—rather than replaces—human-centered care.

Reconstruction of mandibular defects using free fibula flaps with a spliced surgical template system.

Accuracy of static-guided pterygoid implant placement using mucosa-tooth-supported titanium templates: a retrospective cohort study.

Pediatric Microsurgery Part II.

Pediatric Microsurgery Part I.

Towards a widespread usage of computational fluid dynamics simulations for automated virtual nasal surgery planning

The cortical shell technique lacks anatomical guidance for harvesting and grafting. This study compares the horizontal bone gain and neurosensory function of a modified free- hand and a computer-guided cortical shell graft, which was also assessed for accuracy. This study included eighteen patients with atrophic mandibles. Nine patients received free-hand cortical shell harvest, lateral convey, and fixation (the control group), and nine patients received guided workflow (the test group) that utilized cutting and positional guides. The interpositional gap was packed with autogenous particulates from the retromolar bone. The radiographic horizontal bone gain and neurosensory function were compared between the two groups, and the accuracy of the digital workflow was assessed by superimposing and calibrating the planned and immediate postoperative horizontal bone dimensions. The mean horizontal bone gain of the study group recorded (4.93±0.64) mm versus (4.46 ± 0.67) mm for the control group after four months, with a difference of (0.47) mm, which was statistically significant (p=0.038*). The neurosensory function was indifferent in both groups, as all the patients recovered and were graded as (S4) after two months. Finally, the superimposed scans demonstrated close adherence to the virtual plan, with an insignificant difference between the planned and gained horizontal dimensions (p = 0.9). The digital workflow of the modified cortical shell harvest, positioning and fixation enabled precise graft harvest and orientation, with a statistically significant horizontal bone gain exceeding that of the free-hand technique, while neurosensory affection was similar between both groups.

Atrophic jaws are frequently seen in edentulous patients due to early tooth loss, leading to progressive alveolar bone resorption, bone fragility, and increased susceptibility to fractures, even with low-energy trauma. Surgical management of these fractures presents additional challenges, such as reduced bone density, fragment instability, reduced blood flow, and lack of natural occlusal support. With advances in implant-supported rehabilitation, new perspectives have emerged, but risks remain, especially in areas with severe resorption. Iatrogenic fractures can occur during implant placement due to reduced bone thickness. Fracture reduction and adaptation of reconstruction plates are also limited by atrophic anatomy, compromising the stability of osteosynthesis. This paper reports the case of a 55-year-old patient with an iatrogenic fracture in the atrophic mandible after an attempt at dental implant placement. The treatment involved 3-dimensional virtual planning, biomodel printing, and prior adaptation of a reconstruction plate. The use of digital planning contributed to greater predictability, precision, and reduced surgical time. During the postoperative period, the patient developed an infection in the fistula region, which was successfully treated with antimicrobial photodynamic therapy (aPDT) with methylene blue, demonstrating efficacy in controlling the infection and accelerating healing. It is concluded that the management of atrophic mandibles remains challenging, requiring therapeutic individualization, and the use of digital technology through virtual surgical planning and 3-dimensional prototyping has proven to be an important tool in mandibular fracture surgery, although limitations persist regarding the accuracy of condylar positioning in edentulous patients.

The management of dentofacial deformities in completely edentulous patients remains one of the most demanding challenges in maxillofacial surgery due to the absence of occlusal references and severe bone resorption. This systematic review, conducted in accordance with PRISMA guidelines, critically analyzed available evidence on the planning and execution of orthognathic surgery in this population. A comprehensive search of 8 databases identified 8 eligible studies encompassing 34 fully edentulous patients. Le Fort I osteotomy was the predominant procedure (91%), frequently combined with bone grafting and implant-supported rehabilitation (74%). Bilateral sagittal split osteotomy, maxillomandibular advancement, and distraction osteogenesis were less frequent. Digital workflows using virtual planning, CAD/CAM guides, and patient-specific implants demonstrated high positional accuracy (≤1.5mm) and favorable esthetic and functional outcomes. Reported complications were minimal, including 9 implant losses (7.9%) and a single corrected maxillary relapse. Despite the feasibility and promising results, current evidence remains limited and heterogeneous, precluding robust clinical recommendations. Standardized, prospective studies integrating digital and prosthetic protocols are essential to consolidate orthognathic surgery as a safe and reproducible option for the rehabilitation of edentulous patients.

Autologous auricle reconstruction is widely accepted and used, with excellent results obtained from the hands of specialized surgeons. It is nevertheless an ever-evolving and advancing field, at the frontier of science and art, with a difficult surgical learning curve and complex postoperative management. Different strategies are used today, from fashioning the reconstruction from the patient's rib cartilage to bioengineering prosthetics to achieve specific cosmetic and functional outcomes. In this work, the authors present the first true surgical guide to harvest rib cartilage and sculpt a neo-auricle using the contralateral mirrored ear, without the need for additional specific surgical instruments or artistic knowledge. The name "Robert-Houdin Auricle Box" refers to the sawing magic illusion, popularized by the famous French magician Robert-Houdin, in which he was the first to appear to saw an assistant safely in half. The surgeon in this concept performs the same procedure with his scalpel, passing through the 3D printed box slots to safely saw and sculpt the cartilage block trap inside, following an appropriate virtual surgical planning (VSP) session.

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.

To address the issues of low adaptability and significant tracking errors in parking scenarios when using fixed look-ahead distance Pure Pursuit (PP) algorithms, this paper proposes an automatic parking path tracking control algorithm based on Fuzzy Pure Pursuit (FPP). Considering the influence of road curvature on look-ahead distance, a fuzzy controller is designed to output speed proportionality coefficient and curvature proportionality coefficient. This enables adaptive adjustment of the look-ahead distance according to vehicle speed and road curvature, thereby enhancing path adaptability and tracking accuracy. Prescan/CarSim/Simulink simulation results demonstrate that in vertical parking scenarios, the FPP-based tracking control algorithm outperforms traditional PP algorithms in tracking performance for desired paths and heading angles. The tracking error is reduced by 4.8%, and the heading angle error is reduced by 7.3%. The test results of the Apollo advanced platform show that, under different initial heading angles, the vehicle is able to successfully track the parking path and completes the parking operation without collisions. The tracking control algorithm based on FPP has excellent environmental adaptability.

Background: Orthognathic surgery has undergone a significant technological evolution. Digital tools such as virtual surgical planning (VSP), three-dimensional (3D) printing, and computer-aided design/computer-aided manufacturing (CAD/CAM) have become central to the specialty, promising greater precision and predictability. Objective: To synthesize the scientific evidence on new techniques in orthognathic surgery, evaluating their methodologies, clinical outcomes, accuracy, and limitations. Methods: An integrative literature review was conducted in the PubMed/MEDLINE, ScienceDirect, and PMC databases. The search included articles published in the last 20 years using descriptors such as "orthognathic surgery," "virtual surgical planning," "3D printing," "computer-aided surgery," and "surgery-first approach." A total of 22 articles, including reviews, prospective studies, and systematic reviews, were selected. The analysis focused on the description of new techniques, clinical outcomes, and methodological quality, with a qualitative assessment of the level of evidence. Results: The main innovations identified were VSP, 3D-printed surgical guides and custom plates, the surgery-first approach, piezosurgery, and intraoperative navigation. The evidence indicates that these technologies increase surgical accuracy, reduce operative time, and allow for predictable results. VSP shows mean linear deviations of approximately 1.0-1.5 mm. The surgery-first approach reduces total treatment time. However, limitations such as the learning curve, high cost, and challenges in soft tissue prediction persist. Conclusion: New techniques in orthognathic surgery, especially those based on digital workflows, represent a significant advance over conventional methods, offering greater accuracy and efficiency. Despite the promising results, there is a need for more randomized clinical trials to establish a higher level of evidence and standardize protocols.

Orthodontic treatment in cleft lip and palate and craniofacial anomalies is complex and requires a multidisciplinary approach. There are often multiple possible treatment plans. To properly explain and discuss the various options, such as management of frequently missing incisors or the choice between orthognathic surgery and dental compensation, assessment of burden of treatment must be made and adequately communicated to the patients and families. 105 patients affected by cleft lip and palate and craniofacial anomalies were retrospectively collected and divided into two groups. The first group included patients whose orthodontic diagnosis involved missing elements, where treatment could be either space closure or space opening. The second group included patients with skeletal discrepancies, who could be treated with dental compensation ​or with orthognathic surgery. For all patients of both groups two different virtual treatment plans with the Clin Check® software were developed, corresponding to the different treatment possibilities. Clinical aspects which might have influenced treatment choice, such as treatment time, need for extractions, need for prosthetic replacements and need for cooperation were quantified. Logistic regression and Fisher exact test were applied to assess which aspects of treatment led patients to one of the different binary solutions. Length of treatment was not an aspect which differed between choices, while the need for high cooperation and need for tooth extractions were. The clear explanation and visual description of advantages and disadvantages of a treatment, seem to help patients in the selection of the expected solution in terms, not only of final occlusal and aesthetic result, but also in terms of burden of care. Though far from sufficient, the visual tool aids patients and families to take an "informed" decision, with significant legal inferences. Embracing these principles is essential to meet legal standards and foster trust, helping patients make well-informed decisions that align with their personal values and clinical needs. This approach not only respects patient autonomy but also reduces the risk of non-compliance, emotional strain, and potential legal issues, ultimately leading to better therapeutic outcomes and stronger clinician-patient relationships.

Percutaneous transforaminal endoscopic discectomy (PTED) is efficacious for lumbar disc herniation but harbours a steep learning curve and considerable reliance on intraoperative fluoroscopy. This often results in prolonged procedural times and elevated radiation exposure, particularly for novice surgeons. This study evaluates whether preoperative three-dimensional virtual planning using Mimics software improves procedural accuracy and reduces radiation exposure. Sixty-five patients with single-level lumbar disc herniation (L1/2 to L5/S1) were allocated to two cohorts: a conventional group (n = 31) treated based on surgeon experience, and a 3D-planning group (n = 34) undergoing preoperative simulation of skin entry points and trajectories via Mimics. Primary outcomes included fluoroscopy frequency, number of puncture attempts, operative duration, and complication rates. Clinical outcomes (VAS, ODI) were documented as secondary measures. The 3D-planning group demonstrated significantly reduced channel establishment time (15.39 ± 2.42 vs. 19.29 ± 5.98min, P < 0.01), fewer intraoperative fluoroscopies (14.48 ± 2.66 vs. 18.56 ± 2.55 exposures, P < 0.01), and shorter endoscopic operating time (52.16 ± 12.54 vs. 75.09 ± 10.28min, P < 0.01). Complication rates were lower in the 3D group (6.45% vs. 14.71%), though this difference did not reach statistical significance (P = 0.05). Both groups exhibited comparable improvements in VAS and ODI at 6-month follow-up. Preoperative 3D virtual planning enhances procedural precision, reduces radiation exposure, and improves safety in PTED, proving particularly beneficial for surgeons during the initial learning curve.