J Oral Maxillofac Surg

67:2080-2092, 2009

Three-Dimensional Treatment Planning

of Orthognathic Surgery in the Era of
Virtual Imaging
Gwen R.J. Swennen, MD, LDS, DMD, PhD, FEBOMFS,*
Wouter Mollemans, MSc, PhD,† and Filip Schutyser, MSc‡

Purpose: The aim of this report was to present an integrated 3-dimensional (3D) virtual approach
toward cone-beam computed tomography-based treatment planning of orthognathic surgery in the
clinical routine.
Materials and Methods: We have described the different stages of the workflow process for routine
3D virtual treatment planning of orthognathic surgery: 1) image acquisition for 3D virtual orthognathic
surgery; 2) processing of acquired image data toward a 3D virtual augmented model of the patient’s head;
3) 3D virtual diagnosis of the patient; 4) 3D virtual treatment planning of orthognathic surgery; 5) 3D
virtual treatment planning communication; 6) 3D splint manufacturing; 7) 3D virtual treatment planning
transfer to the operating room; and 8) 3D virtual treatment outcome evaluation.
Conclusions: The potential benefits and actual limits of an integrated 3D virtual approach for the
treatment of the patient with a maxillofacial deformity are discussed comprehensively from our expe-
rience using 3D virtual treatment planning clinically.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:2080-2092, 2009

Recent advances in 3-dimensional (3D) medical im-
age computing for orthognathic surgery have en-
abled a major breakthrough and allowed unprecedented
virtual diagnosis, treatment planning, and evaluation of
treatment outcomes of maxillofacial deformities. How-
ever, to enable the clinician to make this major para-
digm shift in routine planning of orthognathic surgery,
both image acquisition systems and 3D virtual planning
software must become user-friendly, easily accessible,
and available at a relatively low cost.
*Private Practice, Division of Maxillofacial Surgery, Department of
Surgery, General Hospital St-Jan Bruges, Bruges, Belgium, Associate
Professor, Medical University Hannover, Hannover, Germany; and
Co-Founder, 3D Facial Imaging Research Group, Bruges, Belgium.
†Research Engineer, Medical Image Computing, University Hos-
pital Gasthuisberg Faculties of Medicine and Engineering, Leuven,
and Digital Dentistry of Medicim, Mechelen, Belgium.
‡Global Solutions Manager, Digital Dentistry of Medicim,
Mechelen, Belgium.
W.M. and F.S. are members of the Nobel Biocare Group.
Address correspondence and reprint requests to Dr Swennen:
Division of Maxillofacial Surgery, Department of Surgery, General
Hospital St-Jan Bruges, Ruddershove 10, Bruges 8000 Belgium,
e-mail: gwen.swennen@azbrugge.be
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6710-0007$36.00/0
doi:10.1016/j.joms.2009.06.007
To reach the present stage in which an integrated
approach of 3D orthognathic surgery has become
feasible, a lot of problems had to be solved. First, 3D
imaging of the patient in the natural head position
(NHP), capturing the hard and soft tissues and teeth,
had to be possible at a low radiation dose. All con-
ventional tools for planning of orthognathic surgery
such as cephalometry, anthropometry of the face,
dental model analysis, plaster dental model surgery,
and soft-tissue simulation had to be developed and
implemented in a single software platform.
The aim of the present study was to report a work-
flow process (Fig 1) for routine 3D treatment plan-
ning of orthognathic surgery in the era of virtual
imaging consisting of 1) image acquisition for 3D
virtual orthognathic surgery; 2) processing of the ac-
quired image data toward a 3D virtual augmented
model of the patient’s head; 3) a 3D virtual diagnosis
of the patient; 4) 3D virtual treatment planning of the
orthognathic surgery; 5) 3D virtual treatment plan-
ning communication; 6) 3D splint manufacturing; 7)
3D virtual treatment planning transfer to the operat-
ing room; and 8) 3D virtual treatment outcome eval-
uation.
We have not intended to provide evidence but to
discuss comprehensively the benefits and the poten-
tial, but especially the actual, limits as determined
from our experience with 3D virtual treatment plan-
ning of orthognathic surgery clinically. We have

2080
SWENNEN, MOLLEMANS, AND SCHUTYSER
FIGURE 1. Workflow process for 3D virtual treatment planning of orthognathic surgery. Note, the different steps of the 3D workflow process
are illustrated using a clinical case other than the case discussed in this article.
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.
therefore referred, in particular, to our work and have
credited all other research groups in this field. Finally,
3D virtual treatment planning requires a good under-
standing of the patient’s needs, a good clinical exam-
ination, and clinical experience.
Image Acquisition for 3D Virtual
Orthognathic Surgery
To enable proper planning of orthognathic surgery,
the patient should undergo imaging in the NHP with
relaxed facial soft tissues. The introduction of cone-
beam computed tomography (CBCT) scanners with
the potential to vertically scan the patient with a low
radiation dose1 and a scanned volume large enough to
capture the entire face (triad of hard and soft tissues
and teeth) will revolutionize how orthognathic sur-
gery will be planned in the future.2 CBCT is a volu-
metric image acquisition technique that offers unique
accessibility because of its low costs compared with
multislice CT (MSCT) and the potential for in-office
imaging. The ideal CBCT apparatus for 3D virtual
treatment planning of orthognathic surgery, however,
is not yet available. A number of problems will be
encountered in the routine clinical situation. First, the
scanned volume of CBCT scanners is currently too
small to capture all types of maxillofacial deformities
(Fig 2). Depending on the type of CBCT scanner, the
2081
field of view is too short in height and does not allow
scanning of the patient from the upper limit of the
thyroid up to 2 cm above the superior orbital rim.
Other CBCT scanners have a field of view that is too
short in depth and do not allow capturing both pori-
ons and the tip of the nose with a sufficient free
margin. The image volume of CBCT is dependent on
the shape of the x-ray beam and the size of the flat
panel detector. Owing to the relatively small detector
size of the available CBCT apparatus, the scanned
volume is limited. With the fast evolution in detector
technology, it is expected that CBCT with larger de-
tectors will become available and eliminate this limi-
tation in the near future. Second, because of the limits
in the scanned volume, accurate positioning of the
patient in the NHP in the CBCT apparatus is some-
times difficult or not feasible. Because of the long
scan times (eg, 40 s with the Iluma CBCT, Imtec,
Ardmore, OK) or 2 scan times (eg, 2 ⫻ 20 s with the
classic iCAT CBCT, Imaging Sciences International,
Hatfield, PA), patients might move during image ac-
quisition, resulting in movement artifacts and useless
data. Improvements in CBCT hardware and software
to allow larger scanned volumes and decreased scan
times are expected to solve these problems in the
near future. Furthermore, in-office CBCT imaging by
experienced personnel is key for good-quality data.
Third, the higher noise level, lower contrast, higher
2082 THREE-DIMENSIONAL TREATMENT PLANNING FOR ORTHOGNATHIC SURGERY
FIGURE 2. Schematic drawing illustrating scanned volume and
field of view of CBCT apparatus. A field of view of 24 cm ⫻ 24 cm
would be ideal for orthognathic surgery planning of all types of
maxillofacial deformities with a sufficient margin.
Swennen, Mollemans, and Schutyser. Three-Dimensional Treat-
ment Planning for Orthognathic Surgery. J Oral Maxillofac Surg
2009.
resolution, and image quality limitations of CBCT im-
aging compared with MSCT imaging should also be
considered. The gray values of a CBCT scan have no
absolute Hounsfield unit calibration. The gray value of
the same tissue changes between scans and with the
position of that tissue in the field of view of the
scanner. Because most tissue segmentation algo-
rithms are based on thresholding, some anatomic
structures (eg, sella turcica, condyles, orbital walls)
are difficult to visualize anatomically in the 3D viewer.
Several improvements in CBCT reconstruction algo-
rithms have already been made and more are ex-
pected in the near future. Fourth, although CBCT
imaging produces fewer artifacts at the occlusal
level than MSCT imaging, a single scanning proce-
dure of the patient’s head does not allow for accu-
rate occlusal and intercuspidation data. However,
this problem has recently been solved (see below).
Finally, the fast evolution in acquisition software of
CBCT scanners inherently necessitates frequent
software updates for the purchased CBCT appara-
tus. The clinician is, therefore, frequently con-
fronted with changes in image quality or image
artifacts after such software updates, which can be
quite frustrating. Good support from the company
providing the CBCT scanner in case of problems is
therefore essential.
Parallel to the volumetric data acquisition by
CBCT, 3D surface information can be acquired for a
more natural and realistic visualization of the pa-
tient by obtaining the color and texture of the facial
soft tissues. The major advantage of 3D photogra-
phy is the short acquisition time compared with
laser surface scanning of the face. The latter, how-
ever, is more accurate if the scanned patient is not
moving.
Processing of Acquired Image Data for
3D Virtual Augmented Model of
Patient’s Head
The aim of 3D virtual imaging for orthognathic
surgery is to create one virtual anatomic model of the
patient, including the triad of the facial soft mask,
underlying bony structures, and teeth. To enable 3D
virtual treatment planning of orthognathic surgery,
the acquired volumetric CBCT image data are seg-
mented by semiautomated thresholding. The result-
ing surface representations of the patient’s anatomy
are then drawn (rendered) on the computer screen,
given a viewing direction of the virtual camera, called
“surface rendering.” A tetrahedral soft-tissue mesh
can subsequently be built to enable fast soft-tissue
simulation using a biomechanical model.3-5 Although
surface representations of the hard and soft tissues
and teeth can be rendered and visualized in the 3D
viewer of the software, some problems are still
present.
Probably the most important obstacle was the in-
accurate visualization of the interocclusal relation-
ship; however, this issue has been resolved. Gateno et
al6 should be credited for developing the first method
applicable to the clinical routine of orthognathic sur-
gery to integrate accurate dental information into the
patient’s skull. After a long odyssey,7-11 our research
group has succeeded in developing an innovative
technique12 to augment the 3D virtual model of the
patient appropriate for orthognathic surgery treat-
ment planning without the use of plaster dental mod-
els or markers and without deformation of the facial
soft-tissue mask (Figs 3A,B). The method, consisting
of a “triple” CBCT scan procedure with “triple” voxel-
based rigid registration,12 has been validated and used
clinically in more than 200 cases in our department.
The protocol12 consists of 1) a first CBCT scan of the
patient in the NHP with central occlusion and relaxed
lips; 2) a second low-resolution and low-dose CBCT
scan of the patient with a double impression tray in
the mouth; and 3) a high-resolution CBCT scan of the
impression tray. After the “triple” CBCT scan proce-
dure, a 3D virtual model of the patient with accurate
occlusal and intercuspidation data is made using a
SWENNEN, MOLLEMANS, AND SCHUTYSER 2083

FIGURE 3. 3D hard tissue surface representations of patient A, before and B, after, augmenting skull model with detailed occlusal and
intercuspidating data according to “triple” CBCT scan procedure with “triple” voxel-based registration. C, Same patient with detailed soft-tissue
texture information determined from arbitrary set of 2-dimensional photographs (Maxilim, version 2.2.2, Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.

semiautomated procedure and the 3 consecutive
“voxel-based” registrations.12
To improve 3D soft-tissue simulation algorithms
(see below), it was essential to integrate accurate
interocclusal data without any soft-tissue disturbances
into the 3D patient model of the head to secure an
unbiased virtual preoperative setting before virtual
simulation. The next challenge is to further augment
the patient’s CBCT model of the head with detailed
visualization of the dental roots. “Surface rendering”
is based on thresholding and currently leads to im-
proper visualization of certain anatomic structures
(eg, sella turcica, condyles, orbital walls) owing to the
inherent inhomogenity of the CBCT gray value data.
However, a volume of voxels can be rendered with
“volume rendering.” For each voxel, a color and opac-
ity can be assigned, and a projection image according
to the viewing direction of the virtual camera can be
computed and presented on the computer screen.
“Volume rendering” of the acquired image data pro-
vides beautiful anatomic images and is useful for 3D
virtual diagnosis of the patient’s anatomy. Because
“volume rendering” is still computationally complex
and it is expensive to manipulate the image data, it is
not yet suitable for 3D virtual treatment planning
of orthognathic surgery. Therefore, mixing “surface”
2084 THREE-DIMENSIONAL TREATMENT PLANNING FOR ORTHOGNATHIC SURGERY
and “volume” rendering probably will allow one to
combine the benefits of both rendering techniques
and is a very promising approach. It is expected that
this “mixed” visualization approach will become pos-
sible in the near future.
Another issue is that the facial soft-tissue mask
obtained by CBCT imaging looks unnatural and is not
a realistic view of the patient. Sophisticated registra-
tion algorithms to further augment the patient’s CBCT
model of the head with skin texture and color infor-
mation to enable a more natural looking rendering are
already available. Using a 3D photograph13,14 or an
arbitrary set of 2-dimensional photographs15 of the
patient with the same facial expression as during
CBCT scanning, highly detailed texture information
can be added to the skin, segmented out of the CBCT
scan (Fig 3C).
3D Virtual Diagnosis of Patient
The combination of a good clinical examination
and 3D inspection of the virtual model of the patient’s
head has an unprecedented potential toward the di-
agnosis of the patient with a maxillofacial deformity.
Both “volume rendering” and “surface rendering” of-
fer a thorough in-depth 3D virtual inspection of the
patient’s anatomy in the 3D virtual scene. Both view-
ing methods also incorporate the original axial CBCT
slices and coronal and sagittal reconstructions, which
allow 2-dimensional inspection of the patient’s anat-
omy in the 3 standard planes (axial, sagittal, coronal)
and multiplanar planes. A large amount of relevant
clinical information with regard to the patient with a
maxillofacial deformity can be gleaned from these
slices (eg, condylar anatomy, maxillofacial bony and
dental pathologic features, maxillary sinus pathologic
features, nasal septum deviation, hypertrophic infe-
rior turbinates, a restricted airway, dentoalveolar
bone support to the teeth, and the pathway of the
inferior alveolar nerve; Fig 4). Volume rendering is
currently the most appropriate for 3D virtual assess-
ment of the roots of the teeth, the temporomandibu-
lar joints, and the airway (Fig 5; see also Fig 12).
Surface rendering offers great potential to implement
the related data in the 3D virtual viewer such as
virtual measurement and osteotomy tools and virtual
surgical devices (eg, virtual surgical splints). Using
surface rendering (Fig 6), 2 innovative virtual ap-
proaches were developed and subsequently com-
bined by our research group. First, a new virtual
approach was developed in which virtual lateral and
frontal cephalograms were calculated from the CT
(CBCT or MSCT) data set of the patient and linked
with the hard and soft-tissue surface-rendered repre-
sentations. This approach allowed us to bridge con-
ventional cephalometry with 3D cephalometry of
the facial soft-tissue mask and underlying bone and
teeth with a common 3D cephalometric reference
frame.16-18 Second, the “triple CBCT scan protocol”
was developed and validated and allows one to aug-
ment the virtual model of the patient’s head to be
appropriate for orthognathic surgery planning with-
out the use of markers and plaster dental models.7-12
The latter developments were key toward the pre-
sented 3D virtual approach of treatment planning of
orthognathic surgery. A current disadvantage of the
3D virtual approach is the static diagnosis of the
patient. The virtual dynamic diagnosis (four dimen-
sions) of the patient (eg, smile esthetics, habits) has
recently been introduced and will probably be inte-
grated in the future.
3D Virtual Treatment Planning of
Orthognathic Surgery
One of the important advantages of 3D virtual plan-
ning compared with conventional treatment planning
of orthognathic surgery is that the clinician inherently
has more information on the patient’s anatomy during
planning. Moreover, 3D virtual treatment planning
allows one to focus more on 3D facial harmonization,
rather than on the facial profile. A standardized ap-
proach toward 3D virtual treatment planning of or-
thognathic surgery, which includes 4 consecutive vir-
tual planning steps (VPSs) (Fig 7), is used in our
clinical practice: VPS1, 3D Bruges cephalometric anal-
ysis for the ideal facial soft-tissue mask; VPS2, 3D
Bruges 3D soft-tissue analysis; VPS3, 3D virtual osteot-
omies; and VPS4, 3D virtual surgery toward the ideal
facial soft-tissue mask. VPS1 consists of 3D cephalo-
metric analysis (11 angles, 7 linear distances, and 2 facial
proportions) of the hard and soft tissues and teeth using
conventional cephalometric analysis performed in the
oral maxillofacial department of Bruges for clinical
and scientific purposes. Moreover, 4 additional verti-
cal orthogonal measurements (UMcuspr-xPl, UCr-xPl,
UCl-xPl, and UMcuspl-xPl) were included to verify the
vertical position of the repositioned maxilla at 4 levels
(both canines and both mesial buccal cusps of the
first molars) during surgery (see below). VPS2 con-
sists of additional 3D soft tissue cephalometric analy-
sis (2 angles, 10 linear distances, and 4 facial propor-
tions) using direct anthropometric analysis performed
in the oral maxillofacial department of Bruges for
clinical and scientific purposes. In VPS3, the most
performed facial osteotomies (Le Fort I, bilateral sag-
ittal split osteotomy, and chin) are routinely done
virtually, which creates the potential to virtually con-
duct different surgical treatment plans. Finally, VPS4
consists of virtual surgery toward the ideal facial soft-
tissue mask, including virtual occlusal definition. The
latter consists of a best fit between the dental arches
SWENNEN, MOLLEMANS, AND SCHUTYSER 2085

FIGURE 4. A, Coronal slices illustrating nasal septum deviation to left, bilateral hypertrophic inferior turbinates, and lingual anatomic
location of inferior alveolar nerve. B, Sagittal slices illustrating correct condylar seating left and right after data acquisition for 3D virtual
planning. Note, artifacts after hard-tissue surface rendering at level of condylar processes (Maxilim, version 2.2.2, Medicim NV, Mechelen,
Belgium). C, Virtual orthopanthogram (Maxilim, beta-version, Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.
2086 THREE-DIMENSIONAL TREATMENT PLANNING FOR ORTHOGNATHIC SURGERY
FIGURE 5. Volume rendering showing 3D visualization of tooth
roots and volume quantification of airway (Dolphin Imaging 11.0
Premium, Chatsworth, CA).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treat-
ment Planning for Orthognathic Surgery. J Oral Maxillofac Surg
2009.
guided by virtual elastics and subsequently visualized
by a color scale. The present study has not reported in
detail on the different VPSs. Moreover, especially re-
garding VPS1 and VPS2, different surgeons and orth-
odontists have their proper measurements they pre-
fer. Unpublished data, however, from a prospective
study of 50 patients, showed that VPS1 to VPS3 can be
performed within a clinically acceptable period
(VPS1, 11.46 ⫾ 0.23 minutes; VPS2, 3.46 ⫾ 0.18
minutes; and VPS3, 5.38 ⫾ 0.33 minutes). VPS4 was
still very time-consuming (23.17 ⫾ 1.31 minutes) be-
cause of the virtual occlusal definition (15.45 ⫾ 0.87
minutes) and can be improved by increasing the
learning curve and, especially, software improve-
ments. Particularly for nonharmonized orthodontic
dental arches or segmental surgery, virtual occlusal
definition is still very demanding. Improvements in
software are therefore mandatory and could solve this
problem. The routine clinical use of 3D virtual plan-
ning also showed that 3D soft-tissue simulation still
requires a number of improvements and cannot be
relied on, especially for patients with long faces and
asymmetries. One should, therefore, be very careful
with the setup of the ideal virtual 3D soft-tissue planes
(eg, ideal modified Burstone profile plane, ideal mod-
ified Ricketts lip plane), because these planes are
determined by the subnasal and lip soft-tissue land-
marks, which are inherently modified by 3D soft-
tissue simulation that is not yet reliable.
Despite the latter disadvantages, some major advan-
tages were experienced using 3D virtual treatment
planning in the clinical routine compared with con-
ventional orthognathic surgery treatment planning.
First, the occlusal plane cant in the frontal plane can
be accessed much more accurately (and subsequently
transferred to the patient using a 3D surgical splint) in
3 dimensions just as done conventionally (eg, wooden
spatula, face bow transfer). The correction of the
frontal occlusal plane cant has an important effect on
the paranasal area, gonial angles, lower mandibular
borders, and chin. Second, the upper dental midline is
often clinically misjudged, because it is often deter-
mined in a clinical setting for the esthetic collumela-
philtrum unit, which can be deviated (Fig 8; eg, in the
case of frontal occlusal plane tilting, deviated anterior
nasal spine, or nasal floor asymmetry). The upper
dental midline can be assessed more accurately to-
ward the facial midline (and also subsequently trans-
ferred to the patient using a 3D surgical splint) in 3
dimensions, just as conventionally. The upper dental
midline can be corrected by a rotation, translation, or
combined rotation and translation of the maxilla to-
ward the skull base. This will have an important effect
on the symmetry of the lower face and facial harmony
(Fig 9). Third, the chin position and anatomy can be
assessed much more accurately in 3 dimensions in the
frontal (transverse and vertical asymmetries) and base
FIGURE 6. Surface rendering illustrating hard-tissue and transpar-
ent soft-tissue surface representations linked with virtual lateral
cephalogram, allowing thorough in-depth 3D cephalometric anal-
ysis of soft and hard tissues and teeth (Maxilim, version 2.2.2,
Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treat-
ment Planning for Orthognathic Surgery. J Oral Maxillofac Surg
2009.
SWENNEN, MOLLEMANS, AND SCHUTYSER
FIGURE 7. 3D virtual treatment planning after 4 consecutive VPS
1 to 4 performed (Maxilim, version 2.2.2, Medicim NV, Mechelen,
Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treat-
ment Planning for Orthognathic Surgery. J Oral Maxillofac Surg
2009.
(transverse deviations, exostoses, and so forth)
planes. Fourth, because the proximal virtual frag-
ments of the mandible remain stable and thus the
condyles remain seated (if the initial data acquisition
was well done) during virtual surgery, the amount of
mandibular movement (advancement or setback,
clockwise or counterclockwise, and medial or lateral
deviation) can accurately be measured on both sides.
Finally, different virtual surgical treatment plans (eg,
bimaxillary rotation clockwise vs counterclockwise)
can be evaluated. An important issue that remains is
to determine 3D virtual mandibular autorotation, es-
pecially in the case of maxillary extrusion.
3D Virtual Treatment
Planning Communication
One of the major disadvantages of conventional
orthognathic surgery planning is communicating the
treatment plan of a patient determined using the com-
bination of a good clinical examination, clinical expe-
rience, and a broad variety of diagnostic information
such as lateral and frontal cephalograms, clinical stan-
dardized photographs, a profile prediction tracing,
dental models, and model articulator surgery.
Three-dimensional virtual orthognathic surgery
planning has powerful potential as a communication
tool because it offers the possibility to visualize an
integrated treatment plan of the patient as a single
virtual anatomic model including the hard and soft
2087
tissues and teeth. First, the 3D virtual treatment plan
can be saved in a viewer format that can be sent by
electronic mail to the referring orthodontist to com-
municate and discuss the patient’s treatment plan.
Second, the 3D virtual treatment plan can be dis-
cussed with the patient and optimized and individu-
alized to the patient’s needs. Third, the 3D virtual
approach offers an excellent communication tool to
teach contemporary treatment of maxillofacial defor-
mity to residents in orthodontics and oral and maxil-
lofacial surgery. Fourth, the surgeon or orthodontist
can easily communicate the 3D virtual treatment plan
of a difficult case to another colleague worldwide
with more experience with a typical pathologic find-
ing to obtain advice (electronic counseling). Finally,
the 3D virtual approach could improve knowledge
worldwide on maxillofacial deformities with elec-
tronic learning and electronic teaching (Fig 1).
Although 3D virtual treatment planning of orthog-
nathic surgery offers an unprecedented tool in com-
munication with patients and colleagues, it does have
some disadvantages. First, the viewer format of the 3D
virtual treatment planning necessitates a personal com-
puter workstation with good graphic ability, which is
currently not standard. Because recent commer-
cially available personal computers have incorpo-
rated more and more powerful graphic ability, this
problem will soon be eliminated. Also, because 3D
soft-tissue simulation still requires improvement,
one should be careful in communicating this infor-
FIGURE 8. Clinical photograph showing upper dental midline has
not deviated regarding esthetic collumella-philtrum unit (Maxilim,
version 2.2.2, Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treat-
ment Planning for Orthognathic Surgery. J Oral Maxillofac Surg
2009.
2088 THREE-DIMENSIONAL TREATMENT PLANNING FOR ORTHOGNATHIC SURGERY

FIGURE 9. Virtual correction of occlusal plane tilting and upper dental midline deviation by combined rotation and translation to right of maxilla
showing A, effect on mandibular border gonial angle symmetry and chin position. Note, the mandible was put virtually into occlusion with the
repositioned maxilla and the chin was not virtually repositioned. B, Isolated 3D virtual repositioning of the maxilla and visualization of the
intermediate surgical splint to transfer virtual repositioning of the maxilla to the patient (Maxilim, version 2.2.2, Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.
SWENNEN, MOLLEMANS, AND SCHUTYSER 2089

FIGURE 10. 3D virtual intermediate and final surgical splint (Maxilim, version 2.2.2, Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.

mation to the patient, especially for patients with a
long faces and facial asymmetries. It is clear that
soft-tissue simulation algorithms will substantially
improve in the future with the input of a large
amount of 3D data.
3D Surgical Splint Manufacturing
Once the final 3D virtual treatment plan has been
set up, the necessary 3D virtual surgical splints can be
made (Fig 10). Subsequently, the 3D virtual surgical
splints are processed using computer-aided design
and computer-aided manufacturing techniques into
surgical splints that can be used during the actual
surgery. Gateno et al19 have shown that stereolitho-
graphic surgical splints fit the same as conventional
surgical splints. Our research group is currently eval-
uating and validating another process to produce sur-
gical wafers by milling instead of stereolithography.
Compared with conventional surgical splints, 3D vir-
tually made surgical splints using our approach seem
to have the following advantages: 1) the surgical
splints are directly made using the 3D virtual aug-
mented model of the patient without the intermediate
of plaster dental models; and 2) the intermediate 3D
virtually made surgical splint can incorporate more
accurately the surgical treatment plan, especially in
complex cases with combined leveling, rotation, and
translation movements of the jaw. To use the 3D
virtual made surgical splints in the clinical routine of
orthognathic surgery, some important problems still
exist. First, the base material for 3D surgical splint
production must be medically approved. Second, the
3D surgical splints are still too bulky and need to be
trimmed manually by the surgeon, which is time-
consuming. It is expected that this will be solved by
virtual trimming before processing and refinement of
the computer-aided design and computer-aided man-
ufacturing techniques. Finally, the manufacturing of
the 3D surgical splints is still a time-consuming pro-

FIGURE 11. Illustration of synthetic cadaver skull showing use of commercially available calipers to verify the vertical position of the
repositioned maxilla at 4 levels (both canines and both mesial buccal cusps of first molars).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.
2090 THREE-DIMENSIONAL TREATMENT PLANNING FOR ORTHOGNATHIC SURGERY

3D Virtual Treatment Planning Transfer

to Operating Room

The 3D virtual surgical treatment plan can be easily

FIGURE 12. Volume-rendered postoperative frontal view (Max-
ilim, version 2.2.2, Medicim, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treat-
ment Planning for Orthognathic Surgery. J Oral Maxillofac Surg
2009.
cess. The clinician must upload the virtual treatment
planning data to be processed out of office, and the
surgical wafer or wafers need to be shipped back to
the clinician. Decreasing the time for out-of-office
processing or in-office manufacturing could solve this
problem. Finally, 3D surgical splints for segmental
surgery are still very demanding in the presented 3D
virtual approach, because virtual occlusal definition of
the segmented jaws is still very difficult. Once again,
improvements in software will solve this problem.
transferred to the operating room in a viewer format.
Surgeons, anesthesiologists, and nurses have access to
the individualized 3D virtual treatment plan of the
patient at any time during surgery. To transfer the
individualized 3D virtual treatment to the patient, 3D
surgical wafers and calipers are used in our approach.
In our surgical approach, the maxilla is repositioned
and ostheosynthesized first during bimaxillary surgery
in most cases. For maxillary repositioning, the 3D surgi-
cal wafer transfers the entire 3D virtual repositioning of
the maxilla (including rotations, translations, and level-
ing), except for its vertical position to the cranial
base. Theoretically, the vertical position of the re-
positioned maxilla should be verified at only one
point. We currently use commercially available cal-
ipers to verify the vertical position of the reposi-
tioned maxilla at 4 levels (both canines and both
mesial buccal cusps of the first molars) (Fig 11)
using the patient’s 3D cephalometric data. For man-
dibular repositioning, the 3D surgical wafer incor-
porates the 3D virtual repositioning of the mandi-
ble; and for chin repositioning, calipers are used to
transfer the 3D virtual plan. A prospective study is
being conducted to evaluate the accuracy of this
approach of transferring the 3D virtual treatment
plan to the patient. If the results show that this
approach is not accurate enough clinically, other
techniques, such as guidance by intraoperative nav-
igation, intraoperative imaging with C-arm CBCT,
or prebent osteosynthesis plates, should be consid-
ered and investigated.

FIGURE 13. Surface-rendered hard-tissue representations after voxel-based superimpositioning on the cranial base before and 6 months
after bimaxillary surgery (Maxilim, version 2.2.2, Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.
SWENNEN, MOLLEMANS, AND SCHUTYSER
FIGURE 14. Surface-rendered right profile soft-tissue representa-
tions after voxel-based superimpositioning on cranial base before
and 6 months after bimaxillary surgery (Maxilim, version 2.2.2,
Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treat-
ment Planning for Orthognathic Surgery. J Oral Maxillofac Surg
2009.
3D Virtual Treatment
Outcome Evaluation
Probably the most powerful aspect of 3D treatment
planning of orthognathic surgery in the era of virtual
imaging is the unprecedented potential for the evalu-
ation of the treatment outcome (Figs 12-15). The
techniques of voxel-based rigid registration and super-
imposition on a 3D cephalometric reference system
have been extensively described.2 Cevidanes et al20-22
have made a major contribution to the published data
FIGURE 15. Surface-rendered base view of soft-tissue representations after voxel-based superimpositioning on the cranial base before and
6 months after bimaxillary surgery (Maxilim, version 2.2.2, Medicim NV, Mechelen, Belgium).
Swennen, Mollemans, and Schutyser. Three-Dimensional Treatment Planning for Orthognathic Surgery. J Oral Maxillofac Surg 2009.
2091
with their clinical research work. We suggest evalu-
ating the treatment outcome using CBCT imaging in 3
stages. First, CBCT should be performed at 3 to 6
weeks postoperatively to evaluate the accuracy of the
transfer of repositioning the bony parts. Because post-
operative swelling of the buccal mucosa can interfere
with occlusion, it is not recommended to perform
CBCT in the first 2 postoperative weeks. In contrast,
bony consolidation appears at 6 weeks postopera-
tively and will no longer allow for proper virtual
identification of the osteotomy lines. Moreover, post-
operative orthodontics has often been restarted at this
point. Second, CBCT should be performed at 6
months to 1 year postoperatively (once the orthodon-
tic brackets have been removed) to evaluate the soft-
tissue response and the accuracy of the soft-tissue
simulation. Finally, CBCT should be performed at 2
years postoperatively to evaluate the long-term treat-
ment outcome.
Meticulous 3D evaluation of the pretreatment sta-
tus, the 3D virtual treatment goal, and the actual
treatment outcome will bring new insights and sub-
stantial information (eg, on long-term stability, airway
stability, condylar resorption, facial harmony, and es-
thetics) and concepts in orthognathic surgery that
will lead to better care of the patient with a maxillo-
facial deformity.
A large amount of basic laboratory and clinical re-
search has been done by different research groups
worldwide in the field of 3D virtual treatment planning
of orthognathic surgery. The translation of this research
into clinical practice (translational research23,24) has
already shown an unprecedented potential toward
the diagnosis, treatment planning, and evaluation of
the treatment outcomes of maxillofacial deformity.
However, to make the paradigm shift from conven-
tional planning to 3D virtual planning, 3 basic require-
2092 THREE-DIMENSIONAL TREATMENT PLANNING FOR ORTHOGNATHIC SURGERY
ments must be fulfilled: 1) the quality of care needs to
improve; 2) the workflow process should become
more efficient; and 3) the cost should decrease. No
doubt exists any longer that 3D virtual planning def-
initely improves the care of the patient with a maxil-
lofacial deformity. Efficiency difficulties still exist,
however, in both computer hardware and software in
the daily clinical routine. Moreover, both the CBCT
apparatus and the virtual 3D software packages are
too expensive. Hence, the challenge and common
goal is to develop 3D virtual treatment planning of
orthognathic surgery as an efficient and cost-effective
clinical tool that improves the care of the patient with
a maxillofacial deformity.
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