Accuracy Assessment of Virtual Surgical Planning Comparing 3D Virtual Surgical Planning and Post-Operative CBCTs in Surgical Skeletal Class III Cases: A Retrospective Study


  • Mario Palone
  • Gabriella La Falce
  • Paolo Albertini
  • Alberto Del Giudice
  • Ugo Baciliero
  • Francesca Cremonini


Orthodontics, Malocclusion, Angle Class III, Epidemiologic Methods


Objective: To evaluate the accuracy of Virtual Surgical Planning (VSP) comparing VSPs and post-operative CBCT scans in patients undergoing bimaxillary orthognathic surgery of severe Skeletal Class III malocclusion. Material and Methods: Twenty-three patients (9 males and 14 females, mean age 24.1 ± 7.0 years) were selected and submitted to bimaxillary orthognathic surgery. Pre-operative VSPs and post-operative CBCTs were compared using both linear (taking into account four skeletal and six dental landmarks, each one described by the respective coordinates) and angular measures (seven planes in total). The threshold discrepancies for post-operative clinical acceptable results were set at ≤2 mm for liner and ≤4° for angular discrepancies. The mean difference values and its 95% confidence interval were identified, comparing which planned and which obtained in absolute value. Results: There were significant statistical differences for all absolute linear measures investigated, although only two overcome the linear threshold value of 2mm in both X and Y-linear dimensions. Linear deviations in Z-linear dimension do not reach statistical significance. All 12 angular measures reach the statistical significance, although none overcome the threshold angular value of 4°. Angular deviation for roll register the higher accuracy in contrast to pitch and yaw. Conclusion: Virtual surgical planning is a reliable planning method to be used in orthognathic surgery field; as a matter of fact, although some discrepancies between the planned on the obtained are evident, most of them meet the tolerability range.


Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. Am J Orthod Dentofacial Orthop 1998; 113(3):333-43.

Pisani L, Bonaccorso L, Fastuca R, Spena R, Lombardo L, Caprioglio A. Systematic review for orthodontic and orthopedic treatments for anterior open bite in the mixed dentition. Prog Orthod 2016; 17(1):28.

Di Fazio D, Lombardo L, Gracco A, D'Amico P, Siciliani G. Lip pressure at rest and during function in 2 groups of patients with different occlusions. Am J Orthod Dentofacial Orthop 2011; 139(1):e1-6.

Lombardo L, Palone M, Carlucci A, Siciliani G. Clear aligner hybrid approach: A case report. J World Fed Orthod 2020; 9(1):32-43.

Arreghini A, Trigila S, Lombardo L, Siciliani G. Objective assessment of compliance with intra- and extraoral removable appliances. Angle Orthod 2017; 87(1):88-95.

Masucci C, Franchi L, Defraia E, Mucedero M, Cozza P, Baccetti T. Stability of rapid maxillary expansion and facemask therapy: a long-term controlled study. Am J Orthod Dentofacial Orthop 2011; 140(4):493-500.

Lopez MA, Andreasi Bassi M, Confalone L, Gaudio RM, Lombardo L, Lauritano D. Retrospective study on bone-level and soft-tissue-level cylindrical implants. J Biol Regul Homeost Agents 2016; 30(2 Suppl 1):43-8.

Lopez MA, Andreasi Bassi M, Confalone L, Gaudio RM, Lombardo L, Lauritano D. Clinical outcome of 215 transmucosal implants with a conical connection: a retrospective study after 5-year follow-up. J Biol Regul Homeost Agents 2016; 30(2 Suppl 1):55-60.

Lombardo L, Gracco A, Zampini F, Stefanoni F, Mollica F. Optimal palatal configuration for miniscrew applications. Angle Orthod 2010; 80(1):145-52.

Gracco A, Luca L, Cozzani M, Siciliani G. Assessment of palatal bone thickness in adults with cone beam computerised tomography. Aust Orthod J 2007; 23(2):109-13.

Liou EJ. Effective maxillary orthopedic protraction for growing Class III patients: a clinical application simulates distraction osteogenesis. Prog Orthod 2005; 6(2):154-71.

Masucci C, Franchi L, Giuntini V, Defraia E. Short-term effects of a modified Alt-RAMEC protocol for early treatment of Class III malocclusion: a controlled study. Orthod Craniofac Res 2014; 17(4):259-69.

Sitaropoulou V, Yilmaz HN, Yilmaz B, Kucukkeles N. Three-dimensional evaluation of treatment results of the Alt-RAMEC and facemask protocol in growing patients. J Orofac Orthop 2020; 81(6):407-418.

Maino G, Turci Y, Arreghini A, Paoletto E, Siciliani G, Lombardo L. Skeletal and dentoalveolar effects of hybrid rapid palatal expansion and facemask treatment in growing skeletal Class III patients. Am J Orthod Dentofacial Orthop 2018; 153(2):262-8.

Lombardo L, Stefanoni F, Mollica F, Laura A, Scuzzo G, Siciliani G. Three-dimensional finite-element analysis of a central lower incisor under labial and lingual loads. Prog Orthod 2012; 13(2):154-63.

Lombardo L, Toni G, Stefanoni F, Mollica F, Guarneri MP, Siciliani G. The effect of temperature on the mechanical behavior of nickel-titanium orthodontic initial archwires. Angle Orthod 2013; 83(2):298-305.

Lombardo L, Carinci F, Martini M, Gemmati D, Nardone M, Siciliani G. Quantitive evaluation of dentin sialoprotein (DSP) using microbeads - a potential early marker of root resorption. Oral Implantol (Rome) 2016; 9(3):132-42.

Burden DJ, Hunt O, Johnston CD, Stevenson M, O'Neill C, Hepper P. Psychological status of patients referred for orthognathic correction of skeletal II and III discrepancies. Angle Orthod 2010; 80(1):43-8.

Ghorbani F, Gheibollahi H, Tavanafar S, Eftekharian HR. Improvement of Esthetic, Functional, and Social Well-Being After Orthognathic Surgical Intervention: A Sampling of Postsurgical Patients Over a 10-Year Period From 2007 to 2017. J Oral Maxillofac Surg 2018; 76(11):2398-2403.

Manfredini D, Stellini E, Gracco A, Lombardo L, Nardini LG, Siciliani G. Orthodontics is temporomandibular disorder-neutral. Angle Orthod 2016; 86(4):649-54.

Park JH, Yu J, Bullen R. Camouflage treatment of skeletal Class III malocclusion with conventional orthodontic therapy. Am J Orthod Dentofacial Orthop 2017; 151(4):804-11.

Ritto FG, Schmitt ARM, Pimentel T, Canellas JV, Medeiros PJ. Comparison of the accuracy of maxillary position between conventional model surgery and virtual surgical planning. Int J Oral Maxillofac Surg 2018; 47(2):160-6.

Xia JJ, Gateno J, Teichgraeber JF, Christensen AM, Lasky RE, Lemoine JJ, et al. Accuracy of the computer-aided surgical simulation (CASS) system in the treatment of patients with complex craniomaxillofacial deformity: A pilot study. J Oral Maxillofac Surg 2007; 65(2):248-54.

Gateno J, Xia JJ, Teichgraeber JF, Christensen AM, Lemoine JJ, Liebschner MA, et al. Clinical feasibility of computer-aided surgical simulation (CASS) in the treatment of complex cranio-maxillofacial deformities. J Oral Maxillofac Surg 2007; 65(4):728-34.

Kwon TG. Accuracy and reliability of three-dimensional computer-assisted planning for orthognathic surgery. Maxillofac Plast Reconstr Surg 2018; 40(1):14.

Alkhayer A, Piffkó J, Lippold C, Segatto E. Accuracy of virtual planning in orthognathic surgery: a systematic review. Head Face Med 2020; 16(1):34.

Bell WH. Le Forte I osteotomy for correction of maxillary deformities. J Oral Surg 1975; 33(6):412-26.

Development Core Team. R: A Language and Environment for Statistical Computing; 2011.

Kim JY, Lee SJ, Kim TW, Nahm DS, Chang YI. Classification of the skeletal variation in normal occlusion. Angle Orthod 2005; 75(3):311-9.

Lee CH, Park HH, Seo BM, Lee SJ. Modern trends in Class III orthognathic treatment: A time series analysis. Angle Orthod 2017; 87(2):269-78.

Marchetti C, Bianchi A, Bassi M, Gori R, Lamberti C, Sarti A. Mathematical modeling and numerical simulation in maxillofacial virtual surgery. J Craniofac Surg 2007; 18(4):826-32.

Tucker S, Cevidanes LH, Styner M, Kim H, Reyes M, Proffit W, et al. Comparison of actual surgical outcomes and 3-dimensional surgical simulations. J Oral Maxillofac Surg 2010; 68(10):2412-21.

Zinser MJ, Mischkowski RA, Dreiseidler T, Thamm OC, Rothamel D, Zöller JE. Computer-assisted orthognathic surgery: waferless maxillary positioning, versatility, and accuracy of an image-guided visualisation display. Br J Oral Maxillofac Surg 2013; 51(8):827-33.

Mazzoni S, Badiali G, Lancellotti L, Babbi L, Bianchi A, Marchetti C. Simulation-guided navigation: a new approach to improve intraoperative three-dimensional reproducibility during orthognathic surgery. J Craniofac Surg 2010; 21(6):1698-705.

Hsu SS, Gateno J, Bell RB, Hirsch DL, Markiewicz MR, Teichgraeber JF, et al. Accuracy of a computer-aided surgical simulation protocol for orthognathic surgery: a prospective multicenter study. J Oral Maxillofac Surg 2013; 71(1):128-42.

Tonin RH, Iwaki Filho L, Yamashita AL, Ferraz FWDS, Tolentino ES, Previdelli ITDS, et al. Accuracy of 3D virtual surgical planning for maxillary positioning and orientation in orthognathic surgery. Orthod Craniofac Res 2020; 23(2):229-36.

Heufelder M, Wilde F, Pietzka S, Mascha F, Winter K, Schramm A, et al. Clinical accuracy of waferless maxillary positioning using customized surgical guides and patient specific osteosynthesis in bimaxillary orthognathic surgery. J Craniomaxillofac Surg 2017; 45(9):1578-85.

Kim J, Kim J, Jeong C, Cheon K, Cho S, Park I, et al. The accuracy and stability of the maxillary position after orthognathic surgery using a novel computer-aided surgical simulation system. BMC Oral Health 2019; 19:18.

Stokbro K, Aagaard E, Torkov P, Bell RB, Thygesen T. Virtual planning in orthognathic surgery. Int J Oral Maxillofac Surg 2014; 43(8):957-65.

Arreghini A, Lombardo L, Mollica F, Siciliani G. Torque expression capacity of 0.018 and 0.022 bracket slots by changing archwire material and cross section. Prog Orthod 2014; 15(1):53.




How to Cite

Palone, M. ., La Falce, G. ., Albertini, P. ., Giudice, A. D. ., Baciliero, U. ., & Cremonini, F. . (2021). Accuracy Assessment of Virtual Surgical Planning Comparing 3D Virtual Surgical Planning and Post-Operative CBCTs in Surgical Skeletal Class III Cases: A Retrospective Study. Pesquisa Brasileira Em Odontopediatria E Clínica Integrada, 21, e0029. Retrieved from



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