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How Many Oral and Maxillofacial Surgeons Does It Take to Perform Virtual Orthognathic Surgical Planning?

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How Many Oral and Maxillofacial Surgeons Does It Take to Perform Virtual Orthognathic Surgical Planning? CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY How Many Oral and Maxillofacial Surgeons Does It Take to Perform Virtual Orthognathic Surgical Planning? Alexandre Meireles Borba, DDS, PhD,* Dustin Haupt, DDS,y Leiliane Teresinha de Almeida Romualdo, DDS Stud,z Andre Luis Fernandes da Silva, DDS, MSc,x Maria da Grac¸a Naclerio-Homem, DDS, PhD,k and Michael Miloro, DMD, MD{ Purpose: Virtual surgical planning (VSP) has become routine practice in orthognathic treatment plan- ning; however, most surgeons do not perform the planning without technical assistance, nor do they routinely evaluate the accuracy of the postoperative outcomes. The purpose of the present study was to propose a reproducible method that would allow surgeons to have an improved understanding of VSP orthognathic planning and to compare the planned surgical movements with the results obtained. Materials and Methods: A retrospective cohort of bimaxillary orthognathic surgery cases was used to evaluate the variability between the predicted and obtained movements using craniofacial landmarks and McNamara 3-dimensional cephalometric analysis from computed tomography scans. The demographic data (age, gender, and skeletal deformity type) were gathered from the medical records. The data analysis included the level of variability from the predicted to obtained surgical movements as assessed by the mean and standard deviation. For the overall sample, statistical analysis was performed using the 1-sample t test. The statistical analysis between the Class II and III patient groups used an unpaired t test. Results: The study sample consisted of 50 patients who had undergone bimaxillary orthognathic surgery. The overall evaluation of the mean values revealed a discrepancy between the predicted and obtained values of less than 2.0 Æ 2.0 mm for all maxillary landmarks, although some mandibular landmarks were greater than this value. An evaluation of the influence of gender and deformity type on the accuracy of surgical movements did not demonstrate statistical significance for most landmarks (P > .05). *Researcher, Master of Science Program on Integrated Dental kAssociate Professor, Department of Oral and Maxillofacial Sciences, Faculty of Dentistry of the University of Cuiaba, Surgery, Traumatology and Prosthesis, Faculty of Dentistry of the Cuiaba, Brazil; Postdoctorate Researcher, Department of Oral University of S~ao Paulo, S~ao Paulo, Brazil. and Maxillofacial Surgery, Traumatology and Prosthesis, Faculty {Professor, Department Head, and Program Director, of Dentistry of the University of S~ao Paulo, S~ao Paulo, Brazil; Department of Oral and Maxillofacial Surgery, University of Illinois and Visiting Researcher, Department of Oral and Maxillofacial at Chicago College of Dentistry, Chicago, IL. Surgery, University of Illinois at Chicago College of Dentistry, Conflict of Interest Disclosures: Dr Miloro is a consultant for Chicago, IL. AxoGen, Inc, Alachua, FL. All other authors do not have any relevant yChief Resident, Department of Oral and Maxillofacial Surgery, financial relationship(s) with a commercial interest. University of Illinois at Chicago College of Dentistry, Chicago, IL. Address correspondence and reprint requests to Dr Miloro: zDental Undergraduate Student, Faculty of Dentistry of the Department of Oral and Maxillofacial Surgery, University of Illinois Federal University of Minas Gerais, Belo Horizonte, Brazil; Summer at Chicago College of Dentistry, 801 South Paulina Street, MC 835, Course Student, Science Without Borders Program, Department of Chicago, IL 60612-7211; e-mail: [email protected] Oral and Maxillofacial Surgery, University of Illinois at Chicago Received December 28 2015 College of Dentistry, Chicago, IL. Accepted March 13 2016 xFormer Master of Science Student, Master of Science Program on Ó 2016 American Association of Oral and Maxillofacial Surgeons Integrated Dental Sciences, Faculty of Dentistry of the University of 0278-2391/16/00347-5 Cuiaba, Cuiaba, Brazil. http://dx.doi.org/10.1016/j.joms.2016.03.013 1807 1808 TRIDIMENSIONAL ORTHOGNATHIC EVALUATION Conclusions: The method provides a reproducible tool for surgeons who use orthognathic VSP to perform routine evaluation of the postoperative outcomes, permitting the identification of specific variables that could assist in improving the accuracy of surgical planning and execution. Ó 2016 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 74:1807-1826, 2016 Orthognathic surgery has evolved over the past few for surgeons in obtaining accurate and precise orthog- decades, specifically regarding the development of nathic surgical outcomes. tridimensional virtual surgical planning (VSP), which has become the current standard modality for plan- Materials and Methods ning bimaxillary jaw surgery, especially for complex facial asymmetries. Such tools now allow for milli- The present retrospective cohort study included bi- meter identification of skeletal discrepancies and the maxillary (maxillary and mandibular) orthognathic sur- ability to plan individualized virtual surgery that can gery cases performed from April 2012 to August 2015 be used to assist during the actual surgical proce- by 1 surgeon (M.M.) in the Department of Oral and dures.1,2 However, the postoperative outcomes of Maxillofacial Surgery at the University of Illinois at Chi- VSP have not been routinely evaluated; thus, most cago. The predictors of the study were determined by surgeons are not able to determine the accuracy or the pre- and postoperative position of craniofacial land- precision of VSP technology in their practice. marks, which were evaluated to determine the accuracy In the previous era of 2-dimensional assessment and between the predicted and obtained movements using orthognathic planning, the surgeon had the ability to cone beam computed tomography (CT) scans. The de- superimpose the pre- and postoperative cephalo- mographic data of the sample (eg, gender, age, and skel- metric radiographs and promptly and easily observe etal deformity type) were gathered from the electronic the differences in the hard tissue structures between medical records. All the cases were planned using VSP the pre- and postoperative periods. With the current and a technician at 3D Systems (formerly Medical 3-dimensional (3D) development, surgeons do not Modeling, Golden, CO). The present study was per- have the same information available in all 3 axes (x, formed under the principles of the Declaration of Hel- y, and z) by merely superimposing the pre- and postop- sinki and ethical approval by the University of Illinois erative CT scans. An increasing number of studies have institutional review board (approval no. 2015-0184) demonstrated encouraging results for orthognathic was obtained before the beginning of the study. outcomes obtained with VSP, even compared with The inclusion criteria were the availability of VSP the traditional methods using orthognathic model sur- data, with existing pre- and postoperative CT scans ob- gery.3-6 However, most of the studies evaluating 3D tained up to 45 days after surgery. The exclusion assessments are difficult to reproduce by practicing criteria were defined as a low-quality CT scan, the oral and maxillofacial surgeons (OMSs), because absence of discernible teeth required for landmark these analyses tend to involve the result of more identification, and concomitant orthognathic and elaborate research and require software and temporomandibular joint surgery. technical expertise beyond that available in a clinical The pre- and postoperative CT scans were evaluated OMS practice.6,7 using Dolphin Imaging, version 11.7 (Dolphin Imaging Because orthognathic VSP is now commonplace, and Management, Chatsworth, CA). Preoperative CT but requires a third-party company for planning and scan data processing began with digital orientation execution, the logical question is whether it is possible of the skull images, similar to that established in a for an OMS to evaluate the accuracy of orthognathic VSP analysis report from 3D Systems, ensuring consis- VSP as a routine practice in their own office. The tency in the orientation of all 3 axes of the skull (x, y, z) objective of the present study was to propose a (Fig 1). Next, the postoperative CT scan was superim- method to compare the planned movements against posed on the preoperative CT scan using an overlay the obtained results in bimaxillary orthognathic cases. method; first, manually to align the base of the skull be- The null hypothesis was that the mean difference be- tween the 2 scans and then refined using the volume/ tween the predicted movements and obtained move- volume auto-superimposition tool by defining the sub- ments using craniofacial landmarks would be region of the anterior cranial fossa (Figs 2 to 5). The 0.0 mm. The results of the present study will allow sur- alignment of the pre- and postoperative skulls was geons to be able to routinely observe the outcomes of visually confirmed in all 3 axes before continuing the VSP process and the clinical significance of any with the analysis. observed differences. This could also assist software The McNamara 3D cephalometric analysis was used companies in developing future scientific studies and to evaluate the selected craniofacial landmarks placed software programs to overcome the present obstacles by a single operator for both the pre- and the BORBA ET AL 1809 FIGURE 1. Tridimensional representation of skull A, before and B, after orientation. Borba et al. Tridimensional Orthognathic
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