CRANIOMAXILLOFACIAL DEFORMITIES/SLEEP DISORDERS/COSMETIC SURGERY

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Virtual Orthodontic Surgical Planning 60
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7 to Improve the Accuracy of the 62
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9 Surgery-First Approach: A Prospective 65
10 66
11 Q1 Evaluation 67
12 68
13 Q7 Giovanni Badiali, MD, PhD,* Enrico Costabile, MD,y Elisa Lovero, DDS,z 69
14 Marco Pironi, MD, MSc,x Paola Rucci, MSc, PhD,jj 70
15 Alberto Bianchi, MD, DDS, PhD,{ and Claudio Marchetti, MD DDS# 71
16 72
17 Purpose: We developed an innovative computer-assisted method to increase the accuracy of the 73
18 surgery-first (SF) approach by linking the virtual orthodontic plan (VOP) with the virtual surgical 74
19 plan (VSP). 75
20 Materials and Methods: Fifteen consecutive patients were enrolled from 2013 to 2015. All 15 76
21 patients had initially undergone cone-beam computed tomography (CBCT; 15  15 field-of-view) and 77
22 intraoral digital scanning of the dental arches. The DICOM (Digital Imaging and Communications in Med- 78
23 icine) data set and STL files were processed using the SimPlant O&O platform (Dentsply-Sirona, York, 79
24 PA), which facilitates skeletal, dental, and soft tissue modeling and subsequent realization of the 80
25 VOP/VSP. The VSP was reproduced using computer-aided design and computer-aided manufacturing sur- 81
26 gical splints, and the VOP was realized via postoperative orthodontic treatment. At the end of treatment, 82
27 all the patients underwent repeat CBCT and digital scanning of the dental arches, and the new data sets 83
28 were compared with the original data sets to determine the deviations. To evaluate skeletal accuracy, we 84
29 assessed all points within an arbitrary range of 2 to +2 mm. To evaluate dental accuracy, the arbitrary 85
30 range was 0.8 to +0.8 mm. 86
31 Results: The average duration of orthodontic treatment was 17.9 months. The accuracy of maxillary 87
32 treatment averaged 0.0702  2.0724 mm and that of mandibular treatment, 0.2811  1.9993 mm. The 88
33 average upper and lower dental arch accuracy was 0.0029  1.125 and 0.0147  1.263 mm, respec- 89
34 tively. The maxillary surgery accuracy was 75.3% and that of mandibular surgery 74.0%, both within the 90
35 2 to +2-mm range. The upper and lower arch accuracy was 58.86 and 51.53%, respectively, both within 91
36 the 0.8 to +0.8-mm range. 92
37 93
38 Conclusions: The use of the VOP/VSP improved the diagnostic and therapeutic SF preoperative plan- 94
39 ning. VOP contributed significantly in this context. The accuracy of skeletal repositioning was acceptable; 95
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41 97
42 Q6 *Research Fellow, Oral and Maxillofacial Surgery, Department of #Full Professor and Head, Division of Oral and Maxillofacial 98
43 Biomedical and Neuromotor Sciences, Alma Mater Studiorum, Surgery, Department of Biomedical and Neuromotor Sciences, 99
44 University of Bologna, Bologna, Italy. Alma Mater Studiorum, University of Bologna, Bologna, Italy. 100
45 yDepartment of Oral and Maxillofacial Surgery, ‘ Vittorio Conflict of Interest Disclosures: None of the authors have any 101
46 Emanuele’’ University Hospital, Catania, Italy. relevant financial relationship(s) with a commercial interest. Q2 102
47 zPhD Student, Division of Oral and Maxillofacial Surgery, Address correspondence and reprint requests to Dr Badiali: 103
48 Department of Biomedical and Neuromotor Sciences, Alma Mater Department of Biomedical and Neuromotor Sciences, Alma Mater 104
49 Studiorum, University of Bologna, Bologna, Italy. Studiorum, University of Bologna, Via S Vitale 59, Bologna 40125, 105
50 xOrthodontist, Private Practitioner, Rimini, Italy. Italy; e-mail: giovanni.badiali@unibo.it 106
51 kAssistant Professor, Division of Hygiene and Biostatistics, Received August 23 2018 107
52 Department of Biomedical and Neuromotor Sciences, Alma Mater Accepted April 15 2019 108
53 Studiorum, University of Bologna, Bologna, Italy. Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral 109
54 {Associate Professor, Division of Oral and Maxillofacial Surgery, and Maxillofacial Surgeons 110
55 Department of General Surgery and Medical-Surgical Specialties, 0278-2391/19/30448-3 111
56 University of Catania, Catania, Italy. https://doi.org/10.1016/j.joms.2019.04.017 112

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113 however, the VSP should be rendered more reproducibly in the future to minimize the need for orthodon- 169
114 tic compensation and to maximize the advantages of SF. 170
115 Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial 171
116 Surgeons 172
117 J Oral Maxillofac Surg -:1-12, 2019 173
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119 175
120 In orthognathic surgery, the surgery-first (SF) cohort of orthognathic patients for whom digital teeth 176
121 approach is a valid alternative to the conventional alignment was used to guide the skeletal movements. 177
122 orthodontics-first (OF) approach. In a recent system- Inspired by these experiences, we developed a new 178
123 Q3 atic review, Peiro-Guijarro et al1 considered the prin- computer-assisted method, which combines the vir- 179
124 cipal advantages of SF to be the reduction in the total tual orthodontic plan (VOP) with the virtual surgical 180
125 orthodontic treatment time, immediate improvement plan (VSP) to increase the accuracy of the SF approach, 181
126 in the facial profile, greater patient satisfaction, and we prospectively studied the clinical outcomes re- 182
127 improved cooperation during postoperative ortho- sulting from its implementation. 183
128 dontic treatment, and improved physiological decom- 184
129 pensation of the arch. However, the SF approach has 185
130 several disadvantages, including a requirement for Materials and Methods 186
131 high-level orthodontic and surgical experience STUDY DESIGN
187
132 when selecting and treating patients, difficulties in 188
133 bonding and management of passive wires, and un- Fifteen consecutive patients who had presented 189
134 stable occlusion in the immediate postoperative with dentofacial deformities at the Oral and Maxillofa- 190
135 period. However, the greatest disadvantage is prob- cial Surgery Unit of the S. Orsola University Hospital in 191
136 ably the reduced predictability of dental movement Bologna (Italy) were enrolled in the present study 192
137 and skeletal surgical correction. To overcome this from 2013 to 2015 and treated by the same orthodon- 193
138 problem, the SF approach requires a precise diag- tist (P.M.). The inclusion and exclusion criteria are 194
139 nosis of the dentoskeletal deformity, personalized or- listed in Table 1. Our local ethics committee approved 195
140 thodontic and surgical planning, and accurate the present monocentric prospective protocol in 2013 196
141 reproduction of the surgical plan in the operating (approval no. 322013USPR). 197
142 room. Only then will the outcomes be both accurate 198
143 and predictable. However, only a few patients have 199
Table 1. INCLUSION AND EXCLUSION CRITERIA
144 been treated via the SF approach, accounting for 200
145 18.8% of those reported by Hernandez-Alfaro et al.2 Criteria 201
146 The principal limitation has been the difficulty in pre- 202
147 dicting the skeletal movement (and, therefore, the Inclusion criteria 203
148 best final occlusion) using traditional 2-dimensional Dentofacial deformity with indications for orthognathic 204
149 surgical planning. Moreover, because the teeth will treatment 205
150 be poorly positioned in their skeletal bases, the Age >18 years 206
151 dental arches will not be mutually matched and, Exclusion criteria 207
152 thus, cannot be used to plan the skeletal movement Class II second division plus overbite 208
Need for SARPE
153 that will resolve the dentofacial deformity.1 209
Any indication for extraction (except for third molars)
154 Although 3-dimensional (3D) virtual planning of Acute periodontal problems
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155 both the skeletal and dental components could over- Severe anesthetic risk 211
156 come these limitations, this method, unlike the OF Any psychiatric pathology 212
157 approach, has seldom been used to assist the SF Alcohol or drug addiction 213
158 approach. Uribe et al3 described 2 cases of facial asym- Pregnancy 214
159 metry treated orthognathically using the SF approach; Severe diabetes 215
160 both surgeries were planned using 3D simulations. Ur- Poor dental hygiene 216
161 ibe et al3 and Janakiraman et al4 both integrated surgi- Current or previous bisphosphonate therapy 217
162 cal simulation with a digital orthodontic setup. Immunodeficiency 218
163 Hernandez-Alfaro et al5 emphasized the benefits of vir- Any severe clinical condition that could interfere with 219
the study
164 tual planning and included virtual 3D orthodontic 220
165 configuration and planning of future dental move- Abbreviation: SARPE, surgically assisted rapid palatal expan- 221
166 ments in their workflow. Im et al6 used surgical and sion. 222
167 orthodontic simulations when planning a single SF Badiali et al. VOP to Improve Surgery-First Approach. J Oral Max- 223
168 case. More recently, Kim et al7 studied a retrospective illofac Surg 2019. 224

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260 FIGURE 1. A, Native dental arches; B, native dental arches with the orthodontic setup of ideal arches; and (Fig 1 continued on next 316
261 page.) 317
262 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019. 318
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PREOPERATIVE CONE-BEAM COMPUTED VOP and VSP. Finally, 3D cephalometry was used to
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TOMOGRAPHY AND INTRAORAL SCANNING OF complete the diagnostic process.
267 DENTAL ARCHES
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269 All 15 patients underwent cone-beam computed to- VIRTUAL ORTHODONTIC PLAN 325
270 mography (CBCT; VGi; NewTom, Verona, Italy) with a For each patient, individualized orthodontic 326
271 15  15 field-of-view and intraoral digital scanning of treatment was created using virtual orthodontic 327
272 the dental arches (Trios; 3Shape, Copenhagen, planning, which permits virtual orthodontic decom- 328
273 Denmark) before treatment. pensation to guide occlusion when planning skel- 329
274 etal movement. The VOP visualizes the teeth, 330
275 HARD AND SOFT TISSUE 3D RECONSTRUCTION including the roots and crowns, as 3D objects. 331
276 The DICOM (Digital Imaging and Communications Also, 3D reconstruction considers the bone associ- 332
277 in Medicine) data set and STL files were processed us- ated with the dental elements. Additionally, 3D 333
278 ing the SimPlant O&O platform (Dentsply-Sirona, translational and rotational movement of all teeth 334
279 York, PA), which allows for skeletal, dental, and soft is allowed. The VOP positions the teeth appropri- 335
280 tissue modeling and subsequent realization of the ately in terms of the skeletal base, yielding an ideal 336

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337 When the IVAs of both arches have been registered 393
338 to the skeletal base in a manner compatible with the 394
339 native arches (Fig 3A,B), VSP can proceed. 395
340 396
341 VIRTUAL SURGICAL PLANNING 397
342 Virtual surgical planning features virtual osteotomy 398
343 (Fig 3C) of the facial skeletal base (eg, Le Fort 1, bilat- 399
344 eral sagittal split osteotomy or segmental osteotomy) 400
345 and subsequent repositioning of the skeletal segments 401
346 (which can be both translated and rotated). First, the 402
347 upper jaw should be repositioned (Fig 3D). This 403
348 should be followed by both the native and the virtually 404
349 planned dental arch. Repositioning should seek to 405
350 fulfill both the esthetic and the cephalometric criteria. 406
351 The lower jaw should be positioned next by reference 407
352 to the IVO (Fig 3E). 408
353 409
354 IDEAL VIRTUAL OCCLUSION 410
355 The IVO is achieved by coordination of the upper 411
356 and lower IVAs. Moving the lower IVA into the IVO 412
357 will allows for automatic repositioning of the lower 413
358 jaw to the final skeletal position (Fig 3). The IVO will 414
359 be achieved by following the 6 occlusal keys of An- 415
360 drews. IVO will be aided by use of a virtual occluso- 416
361 gram (a color-coded map of dental contacts showing 417
362 distances in mm). IVA and IVO are both part of the 418
363 ideal occlusion and, therefore, strongly linked. Never- 419
364 theless, it is methodologically important to consider 420
365 the IVO separately as long as it is serving as a guide 421
366 for the skeletal repositioning. 422
367 423
368 PRELIMINARY ORTHODONTICS 424
369 425
370 The preoperative orthodontics treatment included 426
371 placement of a passive wire 48 hours before surgery. 427
372 We did not use temporary anchorage devices or mini- 428
FIGURE 1 (cont’d). C, ideal virtual arches.
373 plates and did not perform corticotomies. 429
Badiali et al. VOP to Improve Surgery-First Approach. J Oral Max-
374 illofac Surg 2019. 430
SURGICAL PHASE
375 431
376 Jaw osteotomies were performed without using 432
377 virtual arch (IVA) (Fig 1). The upper and lower IVAs surgical cutting guides or computer-assisted piezo- 433
378 are both then coordinated to obtain an ideal virtual surgery.8,9 The VSP was reproduced using 434
379 occlusion (IVO) (Fig 2). The IVA criteria include computer-aided design and computer-aided 435
380 the following: manufacturing (CAD-CAM) surgical splints. Intrao- 436
381 perative navigation and individualized implants 437
382 1. Fitting of incisors to the skeletal base using stan- were not necessary.8,10 The CAD-CAM splints were 438
383 dard cephalometric values (Table 2) manufactured after transfer of the native malocclu- 439
384 2. Creation of a harmonious dental arch with appro- sions to their new skeletal bases (Fig 4). Maxillary 440
385 priate molar and canine transverse widths and mandibular fixation was performed using com- 441
386 3. Distribution of the spaces appropriately to pre- mercial titanium plates and screws (KLS Martin, Tut- 442
387 vent dental overcrowding tlingen, Germany). 443
388 4. Correct vertical positioning of teeth (ensuring a 444
389 satisfactory Spee curve) POSTOPERATIVE ORTHODONTICS 445
390 5. Correct tooth positioning in the alveolar corri- Patients wore the final surgical splints for 30 days 446
391 dors (ensuring a satisfactory Wilson curve) (12 to 24 hours/day), which was the same protocol 447
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FIGURE 2. A, View of a native occlusion; B, matching the native occlusion with the ideal virtual arches; and (Fig 2 continued on next
485 page.) 541
486 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019.
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487 543
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490 we cautiously applied in the OF approach to STATISTICAL ANALYSIS 546
491 achieve the best skeletal stability. Postoperative 547
To estimate the accuracies of the mandibular and
492 orthodontic treatment was then begun, with 548
maxillary surgeries, the percentages of points within
493 549
replacement of the orthodontic wires every 2 to 2 to +2 mm of the planned points were calculated
494 3 weeks. At the end of treatment, all 15 patients un- 550
for each patient. To estimate the accuracies of upper
495 derwent repeat CBCT (without braces, in maximum 551
and lower arch placement, the percentage of points
496 552
intercuspation) and repeat digital scanning of the within 0.8 to +0.8 mm of the planned points were
497 dental arches. 553
calculated for each patient. The latter range was arbi-
498 The post-treatment data sets were used to re-create 554
trarily set smaller than the former to reflect the need
499 3D models, which were compared with the preopera- 555
for greater accuracy in the dental components; thresh-
500 tive virtual plans (both skeletal and dental) using 556
olds less than 1 mm are achievable.
501 Geomagic Design X software (3D Systems, Rock Hill, 557
The Mann-Whitney nonparametric U test for inde-
502 SC), which computed deviations between the 2 558
pendent samples was used to compare the mean
503 models (Fig 5). 559
mandibular and maxillary errors between the groups
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561 Table 2. STANDARD CEPHALOMETRIC VALUES

617
562 618
563 Position Value 619
564 620
565 Upper incisors 621
566 Anteroposterior 4-6 mm in front of point A 622
567 position (according to McNamara) 623
568 Inclination According to angle with 624
569 Arnett’s occlusal plane 625
Lower incisors
570 626
Anteroposterior 2-4 mm in front of point B
571 position (according to McNamara)
627
572 Inclination According to angle with 628
573 Arnett’s occlusal plane 629
574 630
Badiali et al. VOP to Improve Surgery-First Approach. J Oral Max-
575 illofac Surg 2019. 631
576 632
577 633
578 patients presented with treatment failure according 634
579 to the VOP and VSP; therefore, a second surgical pro- 635
580 cedure to establish proper occlusion was not required. 636
581 The deviation measurement ranged from 10 to + 637
582 10 mm for the bone bases and from 5 to +5 mm 638
583 for the dental arches, yielding data on the accuracy 639
584 and precision. 640
585 Registration of the immobile portion of the skull ex- 641
586 hibited a mean error of 0.04 mm and a standard devia- 642
587 tion of 0.848 mm. The average skeletal deviation (from 643
588 0) for each patient is shown in Figure 6. The maxillary 644
589 accuracy averaged 0.0702  2.0724 mm, and the 645
590 mandibular deviation was 0.2811  1.9993 mm. The 646
591 average deviation and standard error of the mandibular 647
592 and maxillary dental arch for each patient (centered on 648
593 the skeleton) are shown in Figure 7. This neglected the 649
594 discrepancies between the skeletal plans and out- 650
595 comes, instead showing the relative accuracy of the 651
596 dental arch with respect to its skeletal base. The 652
597 average upper and lower dental arch accuracy 653
598 FIGURE 2 (cont’d). C, ideal virtual occlusion. was 0.0029  1.125 and 0.0147  1.263 mm, 654
599 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Max- respectively. 655
600 illofac Surg 2019. The root mean square (RMS, or effective) values (ie, 656
601 the quadratic average roots) for the maxilla, mandible, 657
602 and upper and lower arch are shown in Figure 8. The 658
603 in terms of the type of dysmorphia, surgery, maxillary upper arch exhibited a lower RMS value than that of 659
604 advancement, maxillary impaction, maxillary the other bones, indicating better postintervention re- 660
605 lowering, and tilting and translational corrections. positioning. The average accuracy of the maxillary and 661
606 mandibular surgeries was 75.3 and 74.0%, respec- 662
607 tively. The average upper and lower arch accuracy 663
Results
608 was 58.86 and 51.53%, respectively. 664
609 We treated 8 men and 7 women, with a mean age of A significant difference was found between 1-piece 665
610 24.6 years (range, 18 to 44 years). We performed 12 bi- maxillary surgery (mean, 0.129 mm) and multipiece 666
611 maxillary and 3 monomaxillary surgeries (2 upper surgery (mean, 0.554 mm; U test value, 1; 667
612 maxillary and 1 bilateral sagittal split osteotomies). P = .044). Also, a significant difference was found be- 668
613 Four patients underwent upper maxillary segmental tween mandibular movement with (mean, 669
614 surgery (3 Le Fort I 2-piece surgeries and 1 Le Fort I 0.634 mm) and without (mean, 0.0789 mm) transla- 670
615 3-piece surgery). The average orthodontic treatment tion (U test value, 40; P = .019); movement was 671
616 time was 17.9 months (range, 8 to 28 months). No required by patients with severe asymmetries. 672

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720 FIGURE 3. A,B, The ideal virtual arches of both arches were registered on the skeletal base, superimposed on the native arches; C, virtual
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721 surgical plan used to create a virtual osteotomy of the base of the facial skeleton; (Fig 3 continued on next page.) 777
722 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019. 778
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Discussion 3D skeletal and dental imaging have been used to
725 improve treatment planning,11 and virtual orthog- 781
726 In the time since the SF approach was introduced, nathic surgery has been shown to be reliable and accu- 782
727 the need to predict the final occlusion has been rate.12 Hernandez-Alfaro et al5 reported in their study 783
728 increasingly recognized. Several innovative forms of 784

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807 FIGURE 3 (cont’d). D, repositioning of the upper jaw, followed by both the native and the virtually planned dental arches; and E, positioning 863
of the lower jaw by reference to the ideal virtual occlusion.
808 864
809 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019. 865
810 866
811 of 45 patients that ‘‘the necessary dental movements mandibular repositioning (0.0702  2.0724 vs 867
812 were anticipated by performing a 3D virtual orthodon- 0.2811  1.9993 mm). This can be explained by our 868
813 tic setup on the skull model.’’ However, they did not use of a maxilla-first approach. Later mandibular repo- 869
814 describe the VOP.5 Choi et al13 reported that ‘‘simula- sitioning was compromised by any error in maxillary 870
815 tion surgery using a dental model was performed repositioning and worsened when the mandible was 871
816 before surgery to create the appropriate wafer and es- translated. Also, the final orthodontic vertical move- 872
817 timate the extent of postsurgical orthodontic treat- ments could have led to some rotational adjustments 873
818 ment.’’ The procedure resulted in good occlusion of the mandible, providing a further explanation for 874
819 with SF, and cephalometric analysis was used.13 More this result. Nevertheless, these potential adjustments 875
820 recently, Song et al14 used computer-assisted recon- were assumed to have been considered in the VOP/ 876
821 struction (Invivo, version 5.4, software; Anatomage, VSP. Additionally, the accuracy of jaw positioning 877
822 San Jose, CA) to analyze changes in the transverse was notably better when maxillary segmentation was 878
823 dental axes of patients with skeletal Class III malocclu- not required (patients who had undergone 1-piece 879
824 sions and facial asymmetries treated via orthognathic maxilla surgery). The overall precision within the 880
825 surgery with or without additional preoperative ortho- range of 2 to +2 mm was satisfactory, with a signifi- 881
826 dontic treatment. Kim et al7 recently reported a pilot cant number of points overlapping for both jaws 882
827 study of a retrospective cohort of 11 orthognathic (75.3% for the maxilla and 71% for the mandible). 883
828 patients for whom digital teeth alignment was used Thus, CAD-CAM surgical splints allowed for good intra- 884
829 to guide the skeletal movements. They introduced a operative VSP replication. However, the accuracy 885
830 protocol sharing a common underlying principle was inferior to that of other virtual surgical methods 886
831 with that of our study; however, it was retrospective (ie, navigation, CAD-CAM cutting guides/fixa- 887
832 and provided VOP on digital casts without dental roots tion plates).8,10 888
833 (which are required for cephalometric validation).7 Postoperative imaging studies were not conducted 889
834 Moreover, the CAD-CAM–based method used to trans- immediately after surgery. This could have been a lim- 890
835 fer the final occlusion in the operating room was un- itation of the proposed method because when imaging 891
836 clear.7 However, to the best of our knowledge, VOP studies are performed at the post-debonding phase, re- 892
837 quality and accuracy have not been prospectively eval- modeling could have occurred in the operated skel- 893
838 uated in the SF context. eton around the dental–alveolar region. This could 894
839 In terms of reproducibility, our results suggest that affect the VSP accuracy analysis. Such remodeling 895
840 maxillary repositioning will be more accurate than changes would most likely affect the maxilla, where 896

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941 FIGURE 4. A, Osteotomies of jaws with native dental arches; B, repositioning of the jaws guided by the ideal virtual occlusions (IVOs); C, final 997
occlusion obtained by substituting in deal virtual arches for the IVOs in the native dental arches; and D, the intermediate and final computer-
942 aided design and computer-aided manufacturing splints. 998
943 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019.
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947 the buccal cortical bone is thinner and responds more In terms of dental planning reproducibility, the ac- 1003
948 to root movements than does the mandible. However, curacies were satisfactory (0.0029 for the upper 1004
949 the satisfactory accuracy of the maxillary reposition- and 0.0147 mm for the lower arch). However, the 1005
950 ing, together with the small fluctuation around the precision was less satisfactory (58.86 vs 51.58%). 1006
951 optimal value (zero), suggest that this bias did not This was attributed to the reduced thresholding and 1007
952 greatly affect the results of the present analysis. skeletal positioning errors. For example, if the surgeon 1008

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1024 FIGURE 5. Planning parameters and postoperative outcomes were compared in a point-to-point manner using a best-fit algorithm to evaluate 1080
1025 the data by reference to the immobile upper skull (average error, 0.04  0.848 mm). 1081
1026 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019. 1082
1027 1083
1028 1084
has not created a perfect intraoperative replica of the analysis using dental and skeletal landmarks. Neverthe-
1029 1085
VSP, the orthodontist will later be obliged to optimize less, in terms of the effects on facial appearance, the
1030 1086
the occlusion via dental compensation, thus, intro- skeletal and dental surfaces are of paramount impor-
1031 1087
ducing a reproducibility error. tance. Also, the surface analysis will better describe
1032 1088
Use of a surface analysis could miss some clinical as- the biological and mechanical behavior of the jaws
1033 1089
pects when compared with standard cephalometric and teeth in response to treatment.
1034 1090
1035 1091
1036 1092
1037 1093
1038 1094
1039 1095
1040 1096
1041 1097
1042 1098
1043 1099
1044 1100
1045 1101
1046 1102
1047 1103
1048 1104
1049 1105
1050 1106
1051 1107
1052 1108
1053 1109
1054 1110
1055 1111
1056 1112
1057 1113
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1058 1114
1059 1115
1060 1116
1061 1117
1062 1118
1063 FIGURE 6. Average skeletal accuracy. 1119
1064 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019. 1120

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1128 1184
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1136 1192
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1139 1195
1140 1196
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1143 FIGURE 7. Average dental accuracy. 1199
1144 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019. 1200
1145 1201
1146 1202
1147 In terms of the treatment time, the postoperative or- by 1 month; thus, we did not exploit the rapid 1203
1148 thodontic treatment required an average of 17.9 months acceleration phenomenon of the first postoperative 1204
1149 (range, 8 to 28 months), a few months more than that weeks.16 However, both the postoperative orthodontic 1205
1150 after other procedures (average, 14.2 months; range, delay and the exclusion of skeletal anchorage should be 1206
1151 10.2 to 19.4 months).1,15 Although we did not place addressed in future studies to reduce the number of po- 1207
1152 skeletal anchorages (eg, temporary anchorage devices, tential variables when comparing the SF approach with 1208
1153 skeletal anchoring systems), the orthodontic the routine OF approach. 1209
1154 treatment time was not greatly prolonged. Also, we In conclusion, our VOP/VSP method improved the Q4 1210
1155 delayed the beginning of postoperative orthodontics diagnostic and therapeutic preoperative SF planning. 1211
1156 1212
1157 1213
1158 1214
1159 1215
1160 1216
1161 1217
1162 1218
1163 1219
1164 1220
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1167 1223
1168 1224
1169 1225
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1170 1226
1171 1227
1172 1228
1173 1229
1174 1230
1175 FIGURE 8. Quadratic average roots for the maxilla, mandible, and upper and lower arch. RMS, root mean square. 1231
1176 Badiali et al. VOP to Improve Surgery-First Approach. J Oral Maxillofac Surg 2019. 1232

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1233 The skeletal repositioning was acceptable; however, comprehensive workflow based on 45 consecutive cases. J 1268
Oral Maxillofac Surg 72:376, 2014
1234 the reproducibility of the VSP requires future improve- 1269
6. Im J, Kang SH, Lee JY, et al: Surgery-first approach using a three-
1235 ment to minimize orthodontic compensation and dimensional virtual setup and surgical simulation for skeletal 1270
1236 maximize the advantages of the SF approach. The out- class III correction. Korean J Orthod 44:330, 2014 1271
7. Kim JH, Park YC, Yu HS, et al: Accuracy of 3-dimensional virtual
1237 comes were satisfactory. The VPS and VOP data might surgical simulation combined with digital teeth alignment: A pi-
1272
1238 serve as accuracy and precision references for future lot study. J Oral Maxillofac Surg 75:2441.e1, 2017 1273
1239 studies. The VOP contributed significantly to overall 8. Mazzoni S, Bianchi A, Schiariti G, et al: Computer-aided design 1274
and computer-aided manufacturing cutting guides and custom-
1240 planning and might, indeed, be a paradigm of such ized titanium plates are useful in upper maxilla waferless reposi-
1275
1241 planning. We believe that the use of VOP/VSP is un- tioning. J Oral Maxillofac Surg 73:701, 2015 1276
1242 questionably a clinical act and, thus, the primary re- 9. Bianchi A, Badiali G, Piersanti L, Marchetti C: Computer-assisted 1277
piezoelectric surgery: A navigated approach toward perfor-
1243 sponsibility of the orthodontist and surgeon as a mance of craniomaxillofacial osteotomies. J Craniofac Surg 26:
1278
1244 team, with great advantages for both when treating a 867, 2015 1279
1245 patient using the SF approach. 10. Badiali G, Roncari A, Bianchi A, et al: Navigation in orthognathic 1280
surgery: 3D accuracy. Facial Plast Surg 31:463, 2015
1246 11. Okumura H, Chen LH, Tsutsumi S, Oka M: Three-dimensional
1281
1247 References virtual imaging of facial skeleton and dental morphologic condi- 1282
1248 tion for treatment planning in orthognathic surgery. Am J 1283
1. Peiro-Guijarro MA, Guijarro-Martı́nez R, Hernandez-Alfaro F: Sur- Orthod Dentofacial Orthop 116:126, 1999
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gery first in orthognathic surgery: A systematic review of the 12. Liu XJ, Li QQ, Zhang Z, et al: Virtual occlusal definition for
1250 literature. Am J Orthod Dentofacial Orthop 149:448, 2016 orthognathic surgery. Int J Oral Maxillofac Surg 45:406, 1285
1251 2. Hernandez-Alfaro F, Guijarro-Martı́nez R: On a definition of the 2016 1286
appropriate timing for surgical intervention in orthognathic sur- 13. Choi JW, Lee JY, Yang SJ, Koh KS: The reliability of a surgery-first
1252 orthognathic approach without presurgical orthodontic treat-
1287
gery. Int J Oral Maxillofac Surg 43:846, 2014
1253 3. Uribe F, Janakiraman N, Shafer D, Nanda R: Three-dimensional ment for skeletal class III dentofacial deformity. Ann Plast Surg 1288
1254 cone-beam computed tomography-based virtual treatment plan- 74:333, 2015 1289
ning and fabrication of a surgical splint for asymmetric patients: 14. Song HS, Choi SH, Cha JY, et al: Comparison of changes in the
1255 transverse dental axis between patients with skeletal class III
1290
Surgery first approach. Am J Orthod Dentofacial Orthop 144:
1256 748, 2013 malocclusion and facial asymmetry treated by orthognathic sur- 1291
1257 4. Janakiraman N, Feinberg M, Vishwanath M, et al: Integration of gery with and without presurgical orthodontic treatment. 1292
3-dimensional surgical and orthodontic technologies with or- Korean J Orthod 47:256, 2017
1258 15. Jeong WS, Choi JW, Kim DY, et al: Can a surgery-first orthog-
1293
thognathic ‘ surgery-first’’ approach in the management of unilat-
1259 eral condylar hyperplasia. Am J Orthod Dentofacial Orthop 148: nathic approach reduce the total treatment time? Int J Oral Max- 1294
1260 1054, 2015 illofac Surg 46:473, 2017 1295
5. Hernandez-Alfaro F, Guijarro-Martı́nez R, Peiro-Guijarro MA: Sur- 16. Verna C: Regional acceleratory phenomenon. Front Oral Biol 18:
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gery first in orthognathic surgery: What have we learned? A
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