Timing of Three-

Di mensional Virtual
Tre a t m e n t P l a n n i n g o f
Orthognathic Surgery
A Prospective Single-Surgeon Evaluation on
350 Consecutive Cases
Gwen R.J. Swennen, MD, DMD, PhD, FEBOMFS, MSc

KEYWORDS
 Orthognathic surgery  Three-dimensional virtual treatment planning  Virtual planning steps
 Cephalometric analysis

KEY POINTS
 Conventional planning of orthognathic surgery has been well established and provides good
clinical, functional, and aesthetic results.
 3D imaging acquisition and 3D virtual planning of orthognathic surgery provide a new tool to the
clinician to improve both functional and aesthetic results.
 An accurate 3D virtual patient model is essential to avoid errors as in conventional face-bow
transfer.
 Standardizing the different 3D virtual planning steps (3D-VPS1-4) in combination with the proposed
“10 step-by-step” 3D virtual planning protocol (3D-VPS5) allows to integrate “3D virtual treatment
planning” as a new tool in the daily clinical workflow in an efficient and nontime consuming way.
 Both “service-based” and “non–service-based” 3D virtual planning are feasible. Essential is that the
clinician is adequately involved in the actual virtual treatment planning process and has thorough
knowledge on both virtual image acquisition and virtual treatment planning.

Three-dimensional (3D) virtual treatment planning
of orthognathic surgery has already been intro-
duced more than a decade ago1 but is only quiet
recently making a significant breakthrough. Two
major obstacles slowed down its application in
the daily clinical routine: (1) inappropriate hard-
ware for 3D image acquisition of the full face of
the patient and (2) inadequate software for 3D vir-
The introduction of cone-beam computed to-
mography (CBCT) encountered the first obstacle
due to2,3 (1) the potential of scanning the full
face of the patient in a vertical position without
deformation of the soft tissue facial mask; (2)
decreased radiation dose compared with conven-
tional multislice CT scanning; (3) high accessi-
bility; and (4) relative low cost. Meanwhile, the
oralmaxsurgery.theclinics.com

tual diagnosis, treatment planning, and evaluation second obstacle has also been tackled by (1)
of treatment outcome. the establishment and validation of software

The author has nothing to disclose.

No borrowed material was used.
Division of Maxillo-Facial Surgery, Department of Surgery / 3-D Facial Imaging Research Group (3-D FIRG),
General Hospital St-Jan Bruges, Ruddershove 10, Bruges 8000, Belgium
E-mail address: gwen.swennen@azsintjan.be

Oral Maxillofacial Surg Clin N Am 26 (2014) 475–485

http://dx.doi.org/10.1016/j.coms.2014.08.001
1042-3699/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
476 Swennen

protocols to augment the 3D virtual patient model standardized manner with the same software
with accurate occlusal and intercuspidation (Maxilim v2.2.2., Nobel Biocare c/o Medicim NV,
data4,5 and (2) the development of virtual tools Mechelen, Belgium) by the same surgeon (GS).
such as 3D cephalometry, 3D airway analysis, Finally, actual surgery was performed by the
3D virtual osteotomy and occlusal definition, 3D same surgeon (GS) in all patients.
soft tissue simulation, 3D-based surgical splint
and template manufacturing, and finally 3D
superimposition.6–19 STEP-BY-STEP INTEGRATED 3D VIRTUAL
The third actual clinically relevant obstacle TREATMENT PLANNING
toward the routine use of a 3D virtual approach The following 3D-VPS were recorded with a digital
in orthognathic surgery is its integration in the daily chronometer (Xnote Stopwatch v. 1.60).
routine workflow in an efficient and non–time-
consuming way.  (3D-VPS1) 3D “Bruges Target Facial Mask”
Hence, the aim of this prospective study was to cephalometric analysis
evaluate the time needed for routine 3D virtual  (3D-VPS2) 3D additional soft tissue cephalo-
planning of orthognathic surgery in a high- metric analysis
volume clinical setting.  (3D-VPS3) 3D virtual osteotomies
 (3D-VPS4) 3D virtual occlusal definition
PATIENTS  (3D-VPS5) “10 step-by-step” integrated 3D
virtual planning protocol
A prospective single-surgeon (Author Gwen
Swennen [GS]) database (July 1st 2010–June 3D-VPS1 (“Bruges Target Facial Mask” 3D
30th 2014) of the Division of Maxillo-Facial, cephalometric analysis) consists of (1) virtual defi-
Department of Surgery, General Hospital St-Jan nition of the natural head position (NHP) of the pa-
Bruges, Bruges, Belgium was used for this tient; (2) setting up a 3D cephalometric reference
purpose. system20,21; (3) 3D virtual definition of 11 hard tis-
sue, 9 soft tissue, and 12 dental cephalometric
Inclusion criteria: landmarks; and (4) automated calculation of 6
 Consecutive orthognathic patients linear, 10 angular, 2 proportional, and 18 orthog-
 Standardized CBCT image acquisition onal 3D cephalometric hard and soft tissue
 Standardized setup of an augmented 3D vir- measurements (Fig. 1, Table 1) based on the con-
tual patient model in centric relation (CR) ventional “Bruges Target Profile” 2D cephalo-
without the use of plaster dental casts and metric analysis.22 3D-VPS2 consists of a total of
soft tissue deformation
 3D virtual planning steps (3D-VPS1-5) per-
formed by the same surgeon (GS) with the
same planning software
 Surgery performed by the same surgeon (GS)
Exclusion criteria:
 Post-traumatic deformity
 Congenital deformity
 Preprosthetic indication
 Isolated chin osteotomy
 Unilateral sagittal split osteotomy
 Vertical ramus osteotomy
 Segmental surgery
 Le Fort I surgery with mandibular autorotation
All patients underwent standardized CBCT
scanning (i-CAT, Imaging Sciences International,
Inc, Hatfield, USA) in CR following the “triple”
CBCT scan protocol.5 Consequently, standard-
ized 3D augmented virtual patients were made
with detailed occlusal and intercuspidation data
using the “triple” voxel-based rigid registration
protocol (Maxilim v2.2.2., Nobel Biocare c/o Med-
icim NV, Mechelen, Belgium).5 Integrated 3D vir- Fig. 1. 3D-VPS1, “Bruges Target Facial Mask” 3D
tual treatment planning was carried out in a cephalometric analysis.
 Virtual Treatment Planning of Orthognathic Surgery 477

Table 1
3D-VPS1, “Bruges target facial mask” 3D cephalometric analysis

Linear Measurement Analysis

Morphologic height of the face (n-gn)
Height of the face (gl-gn)
Morphologic height of the midface (n-sn)
Height of the midface (gl-sn)
Overbite
Overjet
Angular Measurement Analysis
Upper incisor inclination (MxPl/UIapex-UI)
Lower incisor inclination (MdPl/LIapex-LI)
Frontal inclination of the upper occlusal plane – x-Pl
Frontal inclination of the lower occlusal plane – x-Pl
Frontal inclination of the mandibular plane – x-Pl
Lateral inclination of the upper occlusal plane – x-Pl
Lateral inclination of the lower occlusal plane – x-Pl
Lateral inclination of the mandibular plane – x-Pl
Setup of Bruges ideal target profile plane
Setup of Bruges ideal target lip profile plane
Proportional Measurement Analysis
Morphologic height of the midface/morphologic height of the face (n-sn x 100/n-gn)
Height of the midface/height of the face (gl-sn x 100/gl-gn)
Orthogonal Measurement Analysis
UIr – x-Pl UIr – y-Pl UIr – z-Pl
UIl – x-Pl UIl – y-Pl UIl – z-Pl
UCr – x-Pl UCr – y-Pl UCr – z-Pl
UCl – x-Pl UCl – y-Pl UCl – z-Pl
UMcuspr – x-Pl UMcuspr – y-Pl UMcuspr – z-Pl
UMcuspl – x-Pl UMcuspl – y-Pl UMcuspl – z-Pl
Abbreviations: x-Pl, Horizontal plane; y-Pl, Vertical plane; z-Pl, Median plane.

11 linear, 2 angular, and 5 proportional 3D cepha-
lometric soft tissue measurements after 3D virtual
definition of 18 soft tissue landmarks (Fig. 2,
Box 1) based on the conventional direct anthropo-
metric analysis performed in the Oral & Maxillofa-
cial Surgery department in Bruges. Dynamic
anthropometric measurements could not be per-
formed virtually. As far as 3D-VPS3 is concerned,
chin osteotomy, one-piece Le Fort I, and bilateral
sagittal split osteotomy (BSSO) lines were stan-
dardized and virtually defined in all patients. In
3D-VPS4, virtual occlusal definition was performed
using virtual guiding springs, a best fit algorithm,
and virtual grinding of premature occlusal
contacts.6–12 Finally, 3D-VPS5 consists of a “10
step-by-step” integrated 3D virtual planning proto-
col (Figs. 3–12) that allows to use the 3D virtual
approach as a new tool in combination with clinical
examination based on clinical experience and pa-
tient communication in the daily routine.
“10 Step-By-Step” Integrated 3D Virtual Plan-
ning Protocol (3D-VPS5)
 Step 1: Maxillary occlusal cant evaluation/
correction (“roll”)
 Step 2: Upper dental midline evaluation/
correction
 Step 3: Overall evaluation of facial asymmetry
after virtual occlusal definition
 Step 4: Evaluation/correction of flaring (“yaw”)
 Step 5: Vertical incisal position evaluation/
correction
 Step 6: Sagittal incisal position evaluation/
correction
 Step 7: Profile evaluation/correction (“pitch”)
 Step 8: 3D chin position evaluation/correction
 Step 9: Patient communication of the 3D vir-
tual treatment plan
 Step 10: Final adjustments of the 3D virtual
treatment plan
RESULTS
A total of 350 consecutive orthognathic patients
(men: n 5 104; women: n 5 246) were included
in this study. A total of 324 patients had Class II,
478 Swennen
Fig. 2. 3D-VPS2, 3D soft tissue cephalometric landmarks for additional 3D soft tissue cephalometric analysis.
whereas 26 had Class III maxillofacial deformity.
The mean age of the patients was 25 years (range
15–58 years). The patients included in this study
underwent the following orthognathic surgical pro-
cedures that were all 3D virtually planned and
consecutively operated by the same surgeon
(GS): BSSO (n 5 90); BSSO and chin osteotomy
(n 5 18); Le Fort I and BSSO (n 5 163); and Le
Fort I, BSSO, and chin osteotomy (n 5 79). The in-
dividual timing results for the latter groups for all
VPS are listed in Tables 2–5, respectively. The
overall results showed that 3D-VPS1-4 was per-
formed in the following time frames: 3D-VPS1
(overall mean: 7:30 min; range 7:23–7:37 min);
3D-VPS2 (overall mean: 2:41 min; range 2:38–
2:43 min); VPS3 (overall mean: 3:46 min; range
3:44–3:48 min); and 3D-VPS4 (overall mean:
8:26 min; range 7:40–9:13 min). The overall mean
orthognathic treatment planning time (VPS1–
VPS5) was 29:19 min for BSSO; 29:51 min for
BSSO and chin; 39:31 min for Le Fort I and
BSSO; and 41:01 min for Le Fort I, BSSO, and
chin osteotomy surgical procedures.
THE ADVANTAGES AND LIMITS OF 3D-VPS1
AND 3D-VPS2
The first 2 steps of the virtual planning process,
3D-VPS1 and 3D-VPS2, resemble cephalometric
analysis on lateral and frontal cephalograms and
anthropometric analysis in conventional treatment
planning of orthognathic surgery, respectively.
Both 3D-VPS1 (overall mean: 7:30 min; range
7:23–7:37 min) and 3D VPS2 (overall mean:
3:46 min; range 3:44–3:48 min) could be per-
formed in a more than acceptable clinical time
frame. It has to be emphasized that these VPS
were performed by a clinician (GS), well familiar
and experienced in 3D virtual planning. An initial
learning curve in defining 3D cephalometric land-
marks is obvious as in conventional cephalometry
and anthropometry. In this study, 3D-VPS1 and
3D-VPS2 consisted of a total of 54 automated
measurements after manual definition of 50 land-
marks, based on the conventional “Bruges Target
Profile” 2D cephalometric analysis and direct
anthropometric measurements performed in the
OMF department in Bruges, since the early 90s.
The timing of 3D-VPS1 and 3D-VPS2 can certainly
significantly be decreased by reducing the amount
of measurements and thus the amount of 3D land-
marks to be defined. It is, however, up to each
orthodontic-surgical team to define its proper 3D
cephalometric measurements of soft, hard, and
dental tissues for diagnosis; treatment planning
and transfer; and last but not least evaluation of
treatment outcome according to their proper
philosophy and clinical experience. On the other
hand, semiautomated 3D landmark definition
(where the software automatically defines the 3D
landmarks that consecutively can be modified by
the clinician) will certainly reduce the timing of
3D-VPS1 and 3D-VPS2 in the future. As far as
3D-VPS2 is concerned in particular, CBCT image
acquisition with relaxed lips without disturbing
nasolabial morphology and lip posture is crucial.
 Virtual Treatment Planning of Orthognathic Surgery
Box 1
3D-VPS2, additional 3D soft tissue
cephalometric analysis
Linear Measurement Analysis
Height of the lower face (sn-gn)
Height of the face according to Da Vinci
(right) (osr-gn)
Height of the face according to Da Vinci (left)
(osl-gn)
Height of the skin portion of the upper lip
(philtrum) (sn-ls)
Height of the upper lip (sn-stou)
Interlabial gap (stou-stoi)
Height of the mandible (stoi-gn)
Interpupillary distance (pr-pl)
Intercanthal width (enr-enl)
Upper face width (zyr-zyl)
Morphologic width of the nose according to
Farkas (alr-all)
Angular Measurement Analysis
Nasolabial angle (c’’-sn/ss-ls)
Mentolabial angle (li-sl-pg)
Proportional Measurement Analysis
Facial index (zyr-zyl)  100/(sn-gn)
Bruges index (r) (pr-pl)  100/(osr-gn)
Bruges index (l) (pr-pl)  100/(osl-gn)
Height of the mandible/height of the lower
face (stoi-gn)  100/(sn-gn)
Philtrum/height of the upper lip (sn-ls)  100/
(sn-stou)
Fig. 3. VPS5 Step 1: Maxillary occlusal cant evaluation/correction (“roll”). Note: All virtual osteotomy lines defined
in 3D-VPS3 are shown.
479
Otherwise, 3D cephalometric soft tissue measure-
ments such as nasolabial angle, interlabial gap,
and mentolabial angle will be falsified. On the other
hand, the latter issues are as crucial in conven-
tional imaging and treatment planning of orthog-
nathic surgery. A disadvantage of actual routine
clinical 3D image acquisition is that it only allows
static and no dynamic measurements (eg, teeth
exposure during spontaneous smiling). 4D image
acquisition could potentially solve the latter prob-
lem but is unfortunately currently still “cutting-
edge” technology.22 It is not expected that it will
be available in the daily clinical routine in the
near future due to the high computational
requirements.
THE POTENTIAL OF 3D-VPS3 AND 3D-VPS4
The third step in the virtual planning approach, 3D-
VPS3, can be compared with defining the bony
segments on acetate or digitized cephalometric
tracings in conventional treatment planning of or-
thognathic surgery. 3D-VPS4 resembles the con-
ventional fabrication of a final splint on plaster
dental casts. As far as 3D-VPS3 is concerned,
the virtual approach definitely offers a major
advantage toward the conventional approach. In
the virtual approach, the virtual osteotomy lines
can be 3D designed in both anatomy- and
patient-specific individualized manner, which is
not feasible on conventional acetate or digitized
cephalometric tracings. In this prospective study,
virtual Le Fort I, BSSO, and chin osteotomies
were systematically performed, independent of
the type of maxillofacial deformity to allow flexi-
bility in the final planning process (3D-VPS5).
Nevertheless, the results of this study showed
480 Swennen

Fig. 4. VPS5 Step 2: Upper dental midline evaluation/correction.

Fig. 5. VPS5 Step 3: Overall evaluation of facial asymmetry after virtual occlusal definition. Note: Virtual occlusal
definition (3D-VPS4) is illustrated.

Fig. 6. VPS5 Step 4: Evaluation/correction of flaring (“yaw”).

 Virtual Treatment Planning of Orthognathic Surgery 481

Fig. 7. VPS5 Step 5: Vertical incisal position evaluation/correction.

that 3D-VPS3 could be performed in a clinical
acceptable time frame (overall mean: 3:46 min;
range 3:44–3:48 min).
As far as 3D-VPS4 is concerned, this prospec-
tive study showed that virtual occlusal definition
is still time consuming (overall mean: 8:26 min;
range 7:40–9:13 min) because of the lack of tactile
sense. Moreover, no segmental cases were
included in this study because the 3D virtual plan-
ning software used by the author actually does not
allow accurate routine virtual occlusal definition in
segmental cases. From all VPS, 3D-VPS4 is the
most time-consuming compared with conven-
tional treatment planning where defining the final
occlusion on plaster dental casts is quiet easy
and fast in nonsegmental cases. An alternative vir-
tual approach is the use of plaster dental casts, 3D
scanned in the desired final occlusion. The latter
approach, however, inherently necessitates a sup-
plementary registration process to incorporate the
latter data (plaster dental casts scanned in occlu-
sion) into the 3D virtual patient model. Moreover,
this approach is actually still prone to error due
to weaknesses of the actual registration pro-
cesses. On the other hand, this alternative virtual
approach currently offers a possibility for seg-
mental cases although the potential related error
should be taken into account by the clinician.
THE CLINICAL RELEVANCE OF 3D-VPS5
The major actual challenge for the clinician is to
incorporate 3D imaging and virtual planning as a
new tool in an efficient and non–time-consuming

Fig. 8. VPS5 Step 6: Sagittal incisal position evaluation/correction.

482 Swennen
Fig. 9. VPS5 Step 7: Profile evaluation/correction
(“pitch”).
way in its daily clinical routine planning of orthog-
nathic surgery. The “10 step-by-step” 3D virtual
planning protocol, 3D-VPS5, has been developed
by the author based on his personal experience
with implementing 3D virtual treatment planning
of orthognathic surgery in the daily clinical
workflow. In this prospective study, the “10 step-
by-step” 3D virtual planning protocol was meticu-
lously followed and evaluated regarding timing.
The results of this prospective study showed that
the overall mean orthognathic treatment planning
time (VPS1–VPS5) was clinically more than accept-
able ranging from 29:19 min for a BSSO to
41:01 min for combined Le Fort I, BSSO, and
Fig. 10. VPS5 Step 8: 3D chin position evaluation/correction.
chin osteotomy surgical procedures. Additional
planning of 3D chin repositioning toward BSSO
or bimaxillary surgery did not cause huge differ-
ences in timing (see Tables 3–5). Obviously, bi-
maxillary surgery, with or without chin, was more
time consuming compared with an isolate BSSO
due to the additional planning of bimaxillary rota-
tions (“roll”, “yaw”, and “pitch”) in all 3 planes
(see Figs. 3, 6 and 9).
3D-VPS5 starts from a virtual patient in CR and
in NHP, which has been defined in 3D-VPS1. Im-
age acquisition of a patient in NHP without disturb-
ing the soft tissue facial mask and especially lip
morphology and lip posture is clinically not
feasible. Hence, the head position of each patient
needs to be modified toward its individual NHP
before starting 3D-VPS5. As in conventional treat-
ment planning of orthognathic surgery, it is the re-
sponsibility of the clinician to decide on the NHP of
each individual patient in all 3 planes. In 3D-VPS1,
a 3D cephalometric cranial-based reference
frame21,23 modified from the 2D reference system
described by Profitt24 is nevertheless set up for
objective treatment outcome analysis because it
is well known that treatment-induced changes of
the patient’s NHP can occur in all 3 planes.
The described “10 step-by-step” 3D virtual plan-
ning protocol aims to define an individualized pa-
tient treatment plan that can be modified at each
stage after patient communication. Moreover, it
allows to interactively discuss different potential
treatment options with the patient. The clinician
should, however, be aware of inappropriate 3D
 Virtual Treatment Planning of Orthognathic Surgery 483

Table 2
Results on timing for BSSO (n 5 90)

Mean (min:s) Range (min:s)

3D-VPS1 7:28 6:52–8:10
3D-VPS2 2:41 2:31–2:45
3D-VPS3 3:45 3:20–4:04
3D-VPS4 7:40 3:34–11:40
3D-VPS5 7:45 6:32–8:12
3D-VPS1-5 29:19

Table 3
Results on timing for BSSO and chin osteotomy
(n 5 18)

Mean (min:s) Range (min:s)

Fig. 11. VPS5 Step 9: Patient communication of the 3D
virtual treatment plan.
3D-VPS1 7:23 6:48–8:04
3D-VPS2 2:43 2:34–2:48
3D-VPS3 3:48 3:22–4:09
soft tissue simulation (especially at the level of the 3D-VPS4 7:52 4:12–12:14
lips) in his communication with the patient. The “10
3D-VPS5 8:05 7:48–10:03
step-by-step” 3D virtual planning protocol does
not depend on existing cephalometric analyses 3D-VPS1-5 29:51
and allows the orthodontic-surgical team to use
its proper planning philosophy based on its own
experience especially regarding facial profile anal-
ysis. Toward the transfer of the virtual treatment Table 4
plan in bimaxillary procedures, the “10 step-by- Results on timing for Le Fort I and BSSO
step” 3D virtual planning protocol allows the sur- (n 5 163)
geon to decide if he prefers a “mandible first” or
“maxilla first” surgical procedure, which dictates Mean (min:s) Range (min:s)
3D-VPS1 7:33 6:58–8:22
3D-VPS2 2:38 2:27–2:41
3D-VPS3 3:44 3:17–4:12
3D-VPS4 9:13 4:48–13:41
3D-VPS5 16:23 11:12–19:43
3D-VPS1-5 39:31

Table 5
Results on timing for Le Fort I, BSSO, and chin
osteotomy (n 5 79)

Mean (min:s) Range (min:s)

3D-VPS1 7:37 6:59–8:31
3D-VPS2 2:40 2:33–2:47
3D-VPS3 3:47 3:23–4:11
3D-VPS4 8:58 4:23–12:37
3D-VPS5 17:59 12:58–21:24
Fig. 12. VPS5 Step 10: Final adjustments of the 3D vir-
3D-VPS1-5 41:01
tual treatment plan.
484 Swennen
the fabrication of the intermediate surgical splint.
Last but not least, the “10 step-by-step” protocol
facilitates both “service-based” as “non–service-
based” 3D virtual planning. As far as “service-
based” virtual planning is concerned, all VPS1-5
can be prepared by a technician and consecutively
be verified and eventually modified by the clinician
to decrease the virtual planning time of the
orthodontic-surgical team. “Non–service-based”
3D virtual planning would mean that the clinician
himself performs all (like in this prospective study)
or partially the virtual planning steps (VPS1-5). In an
academic setting, all VPS1-5 could be prepared by
a resident and consecutively be discussed and
modified with the responsible staff member.
Essential in both “service-based” as “non–ser-
vice-based” 3D virtual planning is that the surgeon
who executes the actual surgery is adequately
involved in all VPS1-5 and has thorough knowledge
on both virtual image acquisition and virtual treat-
ment planning to identify the potential errors and
pitfalls based on his clinical experience.
SUMMARY
3D virtual treatment planning of orthognathic sur-
gery provides a potential new routine tool toward
the clinician to improve both functional and
aesthetic treatment outcomes in patients with
maxillofacial deformity. By standardizing the
different virtual planning steps (VPS1-5), the virtual
approach can be integrated in the daily clinical
workflow in an efficient way.
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