Advancements in Computer-Assisted Orthognathic Surgery: A Comprehensive Review and Clinical Application in South Korea.

OBJECTIVES: Orthognathic surgery (OS) has evolved with technological advancements, notably through the implementation of computer-assisted orthognathic surgery (CAOS). This article aims to elucidate various types of CAOS and their efficiency and accuracy, supplemented by a thorough literature review focusing on their clinical applications in South Korea. STUDY SELECTION, DATA, AND SOURCES: A comprehensive search strategy was employed, including systematic reviews, meta-analyses, randomized controlled trials, and observational studies published until December 2023 in the PubMed, MEDLINE, and Google Scholar databases. The literature search was limited to articles written in English. RESULTS: Static CAOS demonstrated high precision, reduced operative time, and high accuracy, suggesting its potential reliability in orthognathic procedures. Dynamic CAOS presented a promising avenue for exploration, showing an accuracy comparable to that of traditional methods. The critical considerations for CAOS include accuracy, time efficiency, and cost-effectiveness. Recent studies have indicated advancements in the time efficiency of static CAOS. Static CAOS requires less equipment and is more cost-effective than dynamic CAOS. CONCLUSION: CAOS offers clear advantages over conventional OS in terms of surgical convenience and accuracy in implementing the surgical plan. To achieve recognition as the gold standard method for maxillofacial deformity treatment, CAOS must overcome its limitations and undergo continuous verification via well-designed studies. CLINICAL SIGNIFICANCE: The introduction of CAOS, mainly static CAOS with high precision and reduced surgical time, signifies a notable advancement in OS. However, rigorous studies are warranted to validate CAOS as the gold standard for treating maxillofacial deformities.

A Comparative Analysis of Artificial Intelligence and Manual Methods for Three-Dimensional Anatomical Landmark Identification in Dentofacial Treatment Planning.

With the growing demand for orthognathic surgery and other facial treatments, the accurate identification of anatomical landmarks has become crucial. Recent advancements have shifted towards using three-dimensional radiologic analysis instead of traditional two-dimensional methods, as it allows for more precise treatment planning, primarily relying on direct identification by clinicians. However, manual tracing can be time-consuming, mainly when dealing with a large number of patients. This study compared the accuracy and reliability of identifying anatomical landmarks using artificial intelligence (AI) and manual identification. Thirty patients over 19 years old who underwent pre-orthodontic and orthognathic surgery treatment and had pre-orthodontic three-dimensional radiologic scans were selected. Thirteen anatomical indicators were identified using both AI and manual methods. The landmarks were identified by AI and four experienced clinicians, and multiple ANOVA was performed to analyze the results. The study results revealed minimal significant differences between AI and manual tracing, with a maximum deviation of less than 2.83 mm. This indicates that utilizing AI to identify anatomical landmarks can be a reliable method in planning orthognathic surgery. Our findings suggest that using AI for anatomical landmark identification can enhance treatment accuracy and reliability, ultimately benefiting clinicians and patients.

Current Status of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) in Maxillofacial Surgery: Should It Be Continued?

Recombinant human bone morphogenetic protein-2 (rhBMP-2) has shown potential in maxillofacial surgery owing to its osteoinductive properties. However, concerns about its safety and high cost have limited its widespread use. This review presents the status of rhBMP-2 use in maxillofacial surgery, focusing on its clinical application, efficacy, safety, and limitations. Studies have demonstrated rhBMP-2's potential to reduce donor site morbidity and increase bone height in sinus and ridge augmentation; however, it may not outperform autogenous bone grafts. In medication-related osteonecrosis of the jaw treatment, rhBMP-2 has been applied adjunctively with promising results, although its long-term safety requires further investigation. However, in maxillofacial trauma, its application is limited to the restoration of large defects. Safety concerns include postoperative edema and the theoretical risk of carcinogenesis. Although postoperative edema is manageable, the link between rhBMP-2 and cancer remains unclear. The limitations include the lack of an ideal carrier, the high cost of rhBMP-2, and the absence of an optimal dosing regimen. In conclusion, rhBMP-2 is a promising graft material for maxillofacial surgery. However, it has not yet become the gold standard owing to safety and cost concerns. Further research is required to establish long-term safety, optimize dosing, and develop better carriers.

Clinical Stability of Bespoke Snowman Plates for Fixation following Sagittal Split Ramus Osteotomy of the Mandible.

Maxillofacial skeletal surgery often involves the use of patient-specific implants. However, errors in obtaining patient data and designing and manufacturing patient-specific plates and guides can occur even with accurate virtual surgery. To address these errors, bespoke Snowman plates were designed to allow movement of the mandible. This study aimed to compare the stability of bespoke four-hole miniplates with that of a bespoke Snowman plate for bilateral sagittal split ramus osteotomy (SSRO), and to present a method to investigate joint cavity changes, as well as superimpose virtual and actual surgical images of the mandible. This retrospective study included 22 patients who met the inclusion criteria and underwent orthognathic surgery at a university hospital between 2015 and 2018. Two groups were formed on the basis of the plates used: a control group with four-hole bespoke plates and a study group with bespoke Snowman plates. Stability was assessed by measuring the condyle-fossa space and superimposing three-dimensional virtual surgery images on postoperative cone-beam computed tomography (CBCT) scans. No significant differences were observed in the condyle-fossa space preoperatively and 1 year postoperatively between the control and study groups. Superimposing virtual surgery and CBCT scans revealed minimal differences in the landmark points, with no variation between groups or timepoints. The use of bespoke Snowman plates for stabilizing the mandible following SSRO exhibited clinical stability and reliability similar to those with bespoke four-hole plates. Additionally, a novel method was introduced to evaluate skeletal stability by separately analyzing the condyle-fossa gap changes and assessing the mandibular position.

Comparative Analysis of Three Facial Scanners for Creating Digital Twins by Focusing on the Difference in Scanning Method.

BACKGROUND: Multi-dimensional facial imaging is increasingly used in hospital clinics. A digital twin of the face can be created by reconstructing three-dimensional (3D) facial images using facial scanners. Therefore, the reliability, strengths, and weaknesses of scanners should be investigated and approved; Methods: Images obtained from three facial scanners (RayFace, MegaGen, and Artec Eva) were compared with cone-beam computed tomography images as the standard. Surface discrepancies were measured and analyzed at 14 specific reference points; Results: All scanners used in this study achieved acceptable results, although only scanner 3 obtained preferable results. Each scanner exhibited weak and strong points because of differences in the scanning methods. Scanner 2 exhibited the best result on the left endocanthion; scanner 1 achieved the best result on the left exocanthion and left alare; and scanner 3 achieved the best result on the left exocanthion (both cheeks); Conclusions: These comparative analysis data can be used when creating digital twins through segmentation, selecting and merging data, or developing a new scanner to overcome all shortcomings.

Effectiveness of cone-beam computed tomography-generated cephalograms using artificial intelligence cephalometric analysis.

Lateral cephalograms and related analysis constitute representative methods for orthodontic treatment. However, since conventional cephalometric radiographs display a three-dimensional structure on a two-dimensional plane, inaccuracies may be produced when quantitative evaluation is required. Cone-beam computed tomography (CBCT) has minimal image distortion, and important parts can be observed without overlapping. It provides a high-resolution three-dimensional image at a relatively low dose and cost, but still shows a higher dose than a lateral cephalogram. It is especially true for children who are more susceptible to radiation doses and often have difficult diagnoses. A conventional lateral cephalometric radiograph can be obtained by reconstructing the Digital Imaging and Communications in Medicine data obtained from CBCT. This study evaluated the applicability and consistency of lateral cephalograms generated by CBCT using an artificial intelligence analysis program. Group I comprised conventional lateral cephalometric radiographs, group II comprised lateral cephalometric radiographs generated from CBCT using OnDemand 3D, and group III comprised lateral cephalometric radiographs generated from CBCT using Invivo5. All measurements in the three groups showed non-significant results. Therefore, a CBCT scan and artificial intelligence programs are efficient means when performing orthodontic analysis on pediatric or orthodontic patients for orthodontic diagnosis and planning.

Fracture and Fatigue of Dental Implants Fixtures and Abutments with a Novel Internal Connection Design: An In Vitro Pilot Study Comparing Three Different Dental Implant Systems.

The aim of this study was to compare the mechanical behaviors of three dental implant fixtures with different abutment connection designs. Three implant systems were studied: the control (BLX implant), test group 1 (TORX++ implant), and test group 2 (IU implant). Three samples from each group were subjected to static compression to fracture tests to determine the maximum fracture load, and twelve samples were exposed to fatigue tests that measured how many cycles the implants could endure before deformation or fracture. Detailed images of the implant-abutment assemblies were obtained using micro-computed tomography imaging, and fractured or deformed areas were observed using a scanning electron microscope (SEM). The mean maximum breaking loads of 578.45 ± 42.46 N, 793.26 ± 57.43 N, and 862.30 ± 74.25 N were obtained for the BLX, TORX++, and IU implants, respectively. All samples in the three groups withstood 5 × 106 cycles at 50% of the nominal peak value, and different fracture points were observed. All abutment connection designs showed suitable mechanical properties for intraoral use. Microscopic differences in the fracture patterns may be due to the differences in the fixture design or abutment connection, and mechanical complications could be prevented by lowering the overload reaching the implant or preventing peri-implantitis.

Finite Element Analysis of a New Non-Engaging Abutment System for Three-Unit Implant-Supported Fixed Dental Prostheses.

(1) Background: The stability of implants plays a significant role in the success of osseointegration. The stability of the connection between the fixture and the abutment is one of the critical factors affecting osseointegration. When restoring multiple, non-parallel, and splinted implants, achieving a passive fit can be complicated and challenging. A new EZ post non-engaging abutment system of the BlueDiamond® (BD) implant allows a wide connection angle while achieving a passive prosthesis fit. This study aimed to confirm the new abutment system's clinical applicability by evaluating its biomechanical characteristics using finite element analysis (FEA). (2) Methods: The implant-supported fixed three-unit dental prostheses model was reproduced for two groups of AnyOne® (AO) and BD implants using FEA. The loading conditions were a preload of 200 N in the first step and loads of 100 N (axial), 100 N (15°), or 30 N (45°) in the second step. (3) Results: The peak Von Mises stress (PVMS) value of the fixture in the BD group was more than twice that in the AO group. In contrast, the PVMS values of the abutment and abutment screws were lower in the BD group than in the AO group. The AO group revealed higher maximal principal stress (MPS) values than that of the BD group in the cortical bone, cancellous bone, and crown. The average stress of the outer surface of the abutment was lower in the AO group than in the BD group. The stress distribution for the inner surface of the fixture confirmed that the BD group displayed a lower stress distribution than the AO group under axial and 15° loads; however, the average stress was 1.5 times higher at the 45° load. The stress values of the entire surface where the cortical and cancellous bone were in contact with the fixture were measured. The AO group showed a higher stress value than the BD group in both cortical and cancellous bone. (4) Conclusions: In the AO group, the PVMS value of the fixture and the stress distribution at the contact surface between the fixture and the abutment were lower than those of the BD group, suggesting that the stability of the fixture would be high. However, due to the high stress in the fastening area of the abutment and abutment screw, the risk of abutment fracture in the AO group is higher than that of the BD group. Therefore, the new EZ post non-engaging abutment of the BD implant can be used without any problems in clinics, similar to the non-engaging abutment of the AO implant, which has been widely used in clinical practice.

Efficacy of Constructing Digital Hybrid Skull-Dentition Images Using an Intraoral Scanner and Cone-Beam Computed Tomography.

Cone-beam computed tomography (CBCT) can distort dentition, and additional imaging is often required. A plaster model to help digitize dental images has been widely used in clinical practice, but there are some inconveniences such as complexity of the process and the risk of damage. The aim of this study was to evaluate the potential for improving dentition imaging with CBCT scans using an intraoral scanner instead of a plaster model. The study used laser model-scanned images of plaster models, imaging from two intraoral scanners, and CBCT images from 20 patients aged 12-18 years. CS 3600 (Carestream Dental, Atlanta, USA) and i700 (Medit, Seoul, Korea) were used as intraoral scanners. The full arch was scanned at once or in three sections using intraoral scanners. The segmented scans were merged to obtain full-arch images. With i700, full-arch images were additionally acquired using its "smart stich" function. The virtual skull-dentition hybrid images obtained from intraoral scanners were superimposed with images obtained using a plaster cast. The difference and distance of coordinate values at each reference point were measured. The average distances from the images obtained with the plaster cast were smaller than 0.39 mm, which is the voxel size of CBCT. Scanning the complete or partial arch using CS 3600 or i700 satisfactorily complemented the CBCT when compared to the plaster model. The virtual skull-dentition hybrid image obtained from intraoral scanners will be clinically useful, especially for patients and surgeons who have difficulty in scanning the complete arch at once.

Three-Dimensional Digital Image Analysis of Skeletal and Soft Tissue Points A and B after Orthodontic Treatment with Premolar Extraction in Bimaxillary Protrusive Patients.

Aim. To investigate the effect of changes in incisor tip, apex movement, and inclination on skeletal points A and B and characterize changes in skeletal points A and B to the soft tissue points A and B after incisor retraction in Angle Class I bimaxillary dentoalveolar protrusion. Methods. Twenty-two patients with Angle Class I bimaxillary dentoalveolar protrusion treated with four first premolar extractions were included in this study. The displacement of skeletal and soft tissue points A and B was measured using cone-beam computed tomography (CBCT) using a three-dimensional coordinate system. The movement of the upper and lower incisors was also measured using CBCT-synthesized lateral cephalograms. Results. Changes in the incisal tip, apex, and inclination after retraction did not significantly affect the position of points A and B in any direction (x, y, z). Linear regression analysis showed a statistically significant relationship between skeletal point A and soft tissue point A on the anteroposterior axis (z). Skeletal point A moved forward by 0.07 mm, and soft tissue point A moved forward by 0.38 mm, establishing a ratio of 0.18: 1 (r = 0.554, p < 0.01). Conclusion. The positional complexion of the skeletal points A and B was not directly influenced by changes in the incisor tip, apex, and inclination. Although the results suggest that soft tissue point A follows the anteroposterior position of skeletal point A, its clinical significance is suspected. Thus, hard and soft tissue analysis should be considered in treatment planning.

Bone Regeneration of a 3D-Printed Alloplastic and Particulate Xenogenic Graft with rhBMP-2.

This study aimed to evaluate the bone regeneration capacity of a customized alloplastic material and xenograft with recombinant human bone morphogenetic protein-2 (rhBMP-2). We prepared hydroxyapatite (HA)/tricalcium phosphate (TCP) pure ceramic bone blocks made using a 3D printing system and added rhBMP-2 to both materials. In eight beagle dogs, a total of 32 defects were created on the lower jaws. The defective sites of the negative control group were left untreated (N group; 8 defects), and those in the positive control group were filled with particle-type Bio-Oss (P group; 12 defects). The defect sites in the experimental group were filled with 3D-printed synthetic bone blocks (3D group; 12 defects). Radiographic and histological evaluations were performed after healing periods of 6 and 12 weeks and showed no significant difference in new bone formation and total bone between the P and 3D groups. The 3D-printed custom HA/TCP graft with rhBMP-2 showed bone regeneration effects similar to that of particulate Bio-Oss with rhBMP-2. Through further study and development, the application of 3D-printed customized alloplastic grafts will be extended to various fields of bone regeneration.

Correction of Condylar Displacement of the Mandible Using Early Screw Removal following Patient-Customized Orthognathic Surgery.

OBJECTIVE: Orthognathic surgery (OGS) is a surgical intervention that corrects dentofacial deformities through the movement of maxillary and mandibular segments to achieve adequate masticatory function, joint health, and facial harmony. However, some patients present with occlusal discrepancies, condylar sag, and/or temporomandibular disorders after OGS. Various methods have been employed to solve these problems after surgery. This study aimed to evaluate the effectiveness of early screw removal in patients with occlusal discrepancies after OGS using three-dimensional cone-beam computed tomography (CBCT). METHODS: In 44 patients with dentofacial deformities, patient-customized OGSs with customized plates were performed to correct facial deformities using customized guides with computer-aided surgical simulation. Of the 44 patients, eight patients complained of occlusal discrepancies and temporomandibular disorders after OGS. These eight patients underwent screw removal under local anesthesia around four weeks. The temporomandibular joint spaces at three time points (pre-surgical, post-surgical, and after screw removal) in the sagittal and coronal planes were compared using CBCT. RESULTS: Eight patients showed an increase in joint space on CBCT images immediately after surgery (T1), but after early screw removal (T2), these spaces almost returned to their pre-surgical state, and the temporomandibular joint problem disappeared. CONCLUSIONS: The removal of screws located in the distal segment under local anesthesia between three and four weeks post-surgically may be a treatment option for patients with post-OGS occlusal discrepancies, condylar sag, and/or temporomandibular disorder.

Sagittal Relationship between the Maxillary Central Incisors and the Forehead in Digital Twins of Korean Adult Females.

OBJECTIVE: Digital twins of adult Korean females were created as a tool to evaluate and compare the sagittal relationship between the maxillary central incisors and the forehead before and after orthodontic treatment. METHODS: Digital twins were reconstructed for a total of 50 adult female patients using facial scans and cone-beam computed tomography (CBCT) images. The anteroposterior position of the maxillary central incisor and the forehead inclination were measured. RESULTS: The control group presented a mean of 6.7 mm for the sagittal position and 17.5° for forehead inclination. The study group showed a mean of 9.3 mm for the sagittal position and 13.6° for forehead inclination. Most Korean females seeking orthodontic treatment had their maxillary central incisor anterior to the glabella. In contrast, fewer Korean females who completed their orthodontic treatments had their maxillary central incisor anterior to the glabella. Furthermore, patients who had completed the orthodontic treatment were more likely to have the maxillary central incisor between the forehead facial axis and glabella. CONCLUSION: The use of digital twins for three-dimensional (3D) analysis of the profile implies a high clinical significance. In addition, as the facial profile of Koreans is different from that of Caucasians, careful consideration should be made when setting treatment goals for the anteroposterior position of the maxillary central incisors.