Virtual planning in orthognathic surgery among Swedish maxillofacial surgeons: a retrospective register-based cohort study

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However, limited information is available regarding the utilization of VSP in Swedish maxillofacial clinics. This study primarily aimed to provide statistical analysis and descriptive statistics on orthognathic surgical parameters in Sweden between 2017 and 2024 and focused on comparing utilization between VSP and conventional surgical planning (CSP). Methods In this retrospective register-based cohort study, statistical analyses were carried out using anonymized data from 2 386 non-syndrome associated patients registered in the Swedish National Registry for Orthognathic Surgery during the years 2017 to 2024. Results The use of VSP among Swedish oral and maxillofacial surgeons significantly increased during the study period. A significant difference was found ( p < 0.001) between VSP and CSP regarding surgery type, intraoperative blood loss for bimaxillary surgery, and surgery time for bimaxillary surgery. VSP is predominantly used in bimaxillary surgery, whereas CSP is more commonly used in single-jaw surgery. Conclusion The findings of this study demonstrate a significant increase in the adoption of VSP among Swedish maxillofacial surgical units between 2017 and 2024, particularly in planning bimaxillary surgeries compared to single-jaw surgeries. In addition, VSP may reduce intraoperative bleeding and shorten surgery time in bimaxillary surgeries compared with CSP. Orthognathic surgery Virtual surgical planning Conventional surgical planning Three-dimensional surgical planning Two-dimensional surgical planning Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Dentofacial deformities are abnormal proportions of the maxillomandibular complex that result in a strongly unfavorable occlusal relationship [ 1 ]. Such deformities lead to varying impairments of jaw function, with associated pain and temporomandibular disorders, negatively impacting masticatory function [ 2 ]. Nevertheless, psychological and aesthetic factors strongly influence the quality of life of patients with dentofacial deformities [ 3 , 4 ]. Orthognathic surgery aims to establish favorable maxillofacial function, normalize facial harmony, and increase health-related quality of life [ 4 – 6 ]. The various indications for surgery include craniofacial deformities, such as cleft lip and palate, increased or reversed overjet, open bite, complete scissors bite, sleep apnea, and skeletal anomalies [ 7 ]. Before surgical correction, it is crucial to conduct a thorough analysis and develop a detailed plan for the surgical procedure to be performed using conventional surgical planning (CSP) or virtual surgical planning (VSP). CSP is performed with two-dimensional radiographs for cephalometric evaluation, plaster dental cast evaluation, and splint preparation [ 1 ]. The method was designed before digitalization and is still widely used today. In contrast, VSP enables surgeons to create a virtual anatomical model of the patient's head and neck, incorporating facial soft tissue, underlying bone structures, and occlusion. A computed tomography (CT) or cone beam computed tomography (CBCT) image is imported into computer software to create a virtual three-dimensional (3D) model for planning [ 8 ]. The 3D model can also visualize potential postoperative outcomes and facilitate determining treatment options for the patient. Individualized wafers are manufactured using computer-aided design and computer-aided manufacturing [ 9 ]. The interocclusal relationship is obtained by using either a 3D surface scanner on traditional cast models of the patient's teeth or an intraoral scanner directly on the patient’s teeth [ 10 ]. Depending on the desired outcome, different surgical techniques are used on both the maxilla and mandible, often foregoing orthodontic treatment and, not uncommonly, are some orthodontics continuing after surgery for final adjustments [ 11 ]. In Sweden, Le Fort I osteotomy is the most common maxillary osteotomy. In the mandible sagittal split osteotomy in the mandible is the most common osteotomy [ 12 , 13 ], usually performed bilaterally. In cases of extensive deviations between the dental arches, osteotomies are performed on both the maxilla and mandible, referred to as bimaxillary surgery. The average prevalence rate of orthognathic procedures between 2010 and 2014 was reported to be 6.3 per 100 000 persons, with 39.4% of patients undergoing bimaxillary surgery, and the mean age at the time of surgery was 22 years [ 13 ]. The first Swedish quality registry for orthognathic surgery (NROK) started in 2017, achieving 91% coverage and good adherence [ 12 ]. Of the 25 maxillofacial surgery units in Sweden that perform orthognathic surgery [ 13 ], 18 are affiliated with NROK. The NROK receives approximately 900 to 1 000 new registrations annually. Orthognathic surgery is generally considered a safe procedure with a very low incidence of complications. However, both intraoperative and postoperative complications can occur. These complications, including surgical blood loss, neurosensory deficits of the inferior alveolar nerve, temporomandibular joint issues, relapse, and local irritation or infection related to osteosynthesis materials, can range from mild to severe [ 14 ]. The recent literature presents conflicting evidence regarding whether VSP or CSP is more cost-effective and less time-consuming. One study indicated that VSP is significantly more cost-effective than CSP in bimaxillary surgery considering reduced preoperative laboratory work, shorter surgery time, and lower planning costs [ 15 ]. Another highlighted the disadvantages of VSP, including the cost of CBCT scans and software, as well as longer planning time [ 16 ]. The average planning time for CSP was reported to be 20 minutes per patient, whereas VSP required 38 minutes on average [ 16 ]. However, over the 1-year evaluation period, planning time with VSP decreased as experience increased, highlighting a learning curve [ 16 ]. The techniques demonstrate comparable accuracy in predicting hard-tissue outcomes, but VSP exhibits superior accuracy in predicting soft-tissue outcomes [ 16 ]. Though both methods have been reported to effectively achieve sagittal correction and high patient satisfaction with results, patients operated on with VSP had better midline alignment, less occlusal plane misalignment, and more balanced ramus inclination, and a greater proportion of patients reported being “very satisfied” with the outcomes [ 17 ]. Surgeons also reported achieving more desirable results with VSP, particularly in terms of mandibular contour symmetry [ 18 ]. Furthermore, studies have shown that VSP provides greater accuracy in predicting anterior maxillary outcomes and offers advantages when planning for correction of facial asymmetry despite both CSP and VSP demonstrating strong overall predictive capabilities for facial outcomes [ 19 – 20 ]. Notably, improvements in facial aesthetics have been observed in patients regardless of the planning method [ 21 ]. Both CSP and VSP are currently used for planning orthognathic surgery, but knowledge of their actual use in Sweden remains limited. Despite studies suggesting potential advantages of VSP in surgical precision, patient satisfaction, and cost-effectiveness, its adoption across surgical units and temporal trends remain largely unexplored. By analyzing these patterns, we aim to contribute to clinical decision-making, resource use, and favorable patient outcomes, as well as increasing understanding the impact of digitalization in surgical planning on efficiency and accuracy, thereby improving patient care for those with dentofacial deformities. This retrospective register-based cohort study aimed to provide a descriptive statistical analysis of orthognathic surgeries in Sweden between 2017 and 2024. The primary objective was to evaluate the use of CSP and VSP among Swedish oral and maxillofacial surgical units that perform orthognathic surgery and to investigate potential temporal trends in their use. The hypothesis was that VSP is more frequently used during bimaxillary surgery. The study also aimed to evaluate the number of included patients, sex distribution, mean surgery time, intraoperative blood loss, and mean age at the time of surgery, as well as provide a descriptive analysis of the numbers of single-jaw and bimaxillary surgeries. MATERIALS & METHODS Study population and data selection In October 2024, NROK provided an anonymized dataset consisting of 2 755 sequence numbers registered from 2017 to 2024. Each unique sequence number corresponds to a patient and serves as an anonymized identifier to evaluate individual patient data without compromising patient confidentiality. The sequence numbers were reviewed for inclusion according to predefined criteria (Fig. 1 ). First, entries associated with craniofacial syndromes or developmental anomalies were removed. A total of 307 diagnostic labels meeting the exclusion criteria were identified; 37 patients had more than one diagnosis recorded and were counted only once. Thus, this categorization represented 270 unique patients who were excluded from the study population. Next, surgery types linked to excluded diagnoses, patients who underwent only genioplasty, and duplicate registrations were excluded. Duplicate entries were identified as the same sequence number appearing in multiple rows in the dataset, indicating that some patients had undergone orthognathic surgery on more than one occasion during the study period. Only the first recorded surgery per patient was included to ensure that each patient contributed only one observation to the analysis and to avoid overrepresentation of individuals with repeated procedures. In addition, 12 patients had no recorded surgery type data, possibly due to our exclusion criteria for the NROK dataset. These patients were not included in the statistical analysis. After applying all exclusion criteria and removing duplicates and entries missing surgery type, 2 386 sequence numbers remained for analysis. These were categorized (see Appendix A) into maxillary surgery (n = 562), mandibular surgery (n = 742), and bimaxillary surgery (n = 1 082). Statistical analysis Statistical analyses were performed using IBM SPSS Statistics (version 28.0, IBM Corp, Armonk, NY, USA). Cross-tabulation was used to analyze potential patterns and correlations for CSP and VSP, as well as the variables used in this study. The significance level was set at p < 0.05. A Pearson chi-squared test was used to assess the significance of differences between CSP and VSP for the variables of interest. The variables of interest were the number of surgeries, number of surgery types (maxillary, mandibular, and bimaxillary), patient sex, intraoperative blood loss (divided into single-jaw and bimaxillary surgery groups; 500 ml), and surgery time (divided into single-jaw and bimaxillary surgery groups; 6 h). Sixty-seven patients with no intraoperative blood loss data recorded and 32 patients with no surgery time data recorded were excluded from the statistical analyses of those variables. RESULTS Descriptive statistics The final sample consisted of 2 386 patients, including 1 109 (46.5%) males and 1 277 (53.5%) females ranging in age from 15 to 71 years, with a mean age of 24.05 years at the time of surgery. Of these 2 386 patients, 1 440 (60.4%) underwent surgery with CSP and 946 (39.6%) with VSP. The descriptive statistics and analysis are provided in Table 1 . Table 1 Descriptive statistics and analysis of the included data Variable of interest CSP, n (%) VSP, n (%) Total, n (%) P-value* Surgery type < 0.001 Maxillary 448 (31.1) 114 (12.1) 562 (23.6) Mandibular 594 (41.3) 148 (15.6) 742 (31.1) Bimaxillary 398 (27.6) 684 (72.3) 1 082 (45.3) Total 1 440 (100) 946 (100) 2 386 (100) Sex 0.199 Male 654 (45.4) 455 (48.1) 1 109 (46.5) Female 786 (54.6) 491 (51.9) 1 282 (53.5) Total 1 451 (100) 947 (100) 2 398 (100) Blood loss, single-jaw surgery 0.233 500 ml 14 (1.4) 6 (2.3) 20 (1.6) Total 1 006 (100) 260 (100) 1 266 (100) Blood loss, bimaxillary surgery < 0.001 500 ml 67 (17.7) 62 (9.2) 129 (12.3) Total 379 (100) 674 (100) 1 053 (100) Surgery time, single-jaw 0.124 6 h 1 (0.1) 2 (0.8) 3 (0.2) Total 1 026 (100) 260 (100) 1 286 (100) Surgery time, bimaxillary < 0.001 6 h 19 (4.9) 12 (1.8) 31 (2.9) Total 387 (100) 681 (100) 1 068 (100) CSP, conventional surgical planning; VSP, virtual surgical planning. *Pearson chi-squared test. Surgery type The analysis revealed a significant difference between the type of surgery performed and the planning method ( p < 0.001). VSP was predominantly used for bimaxillary surgery (72.3%), and CSP was primarily used for single-jaw surgery, both maxillary (31.1%) and mandibular (41.3%). Sex A comparison between sex and the utilization of VSP and CSP showed no significant difference ( p = 0.199). Male patients accounted for 45.4% and female patients for 54.6% of the CSP group. In the VSP group, the sex distribution was 48.1% males and 51.9% females. Bleeding Distribution analysis of intraoperative blood loss during single-jaw surgeries showed no significant difference between CSP and VSP ( p = 0.223). However, a significant difference was observed between CSP and VSP the bimaxillary surgery groups ( p < 0.001). For intraoperative blood loss, the CSP group showed that 18.5% of patients lost 500 ml. In comparison, the VSP group demonstrated 30.1% with 500 ml. Thus, the CSP group had a higher proportion of patients with major blood loss (> 500 ml), whereas the VSP group had a larger proportion with low blood loss (< 200 ml). Surgery time Single-jaw surgeries were generally completed in under 2 hours, while most bimaxillary procedures required 2–4 hours. Surgery time for single-jaw procedures was not significantly different between CSP and VSP ( p = 0.124). In contrast, bimaxillary surgery time showed a significant difference between the groups ( p < 0.001). In the CSP group, 3.4% of surgeries lasted < 2 hours, 64.1% lasted 2–4 hours, 27.6% lasted 4–6 hours, and 4.9% exceeded 6 hours. In the VSP group, 3.5% of surgeries lasted < 2 hours, 74.9% lasted 2–4 hours, 19.8% lasted 4–6 hours, and 1.8% exceeded 6 hours. Bimaxillary surgeries planned with VSP demonstrated fewer procedures exceeding 6 hours and a higher proportion completed within 2–4 hours compared to CSP. Temporal trends of utilization of VSP and CSP We observed a significant increase in the utilization of VSP between 2017 and 2024 compared to CSP ( p < 0.001; Figs. 2 and 3 ). From 2017 to 2020, VSP use increased by 46.8 percentage points, from 3.4% to 50.2%, with an equivalent decrease in CSP use from 96.6% to 49.8%. From 2020 to 2024, the difference between planning methods plateaued. DISCUSSION The purpose of this register-based retrospective study was to compare VSP and CSP in orthognathic surgeries performed in Sweden between 2017 and 2024, focusing on general surgical parameters and usage trends. To the best of our knowledge, this study is the first to compare the utilization of VSP and CSP in orthognathic surgeries using systematically registered data from NROK. Bimaxillary vs. single-jaw surgery This study demonstrates a significant association between planning method and surgery type, with VSP use being substantially more prevalent in bimaxillary surgeries. A likely explanation is that bimaxillary surgery generally involves greater technical complexity and, therefore, benefits from enhanced accuracy, visualization, and predictability provided by VSP. Another explanation can be attributed to the individual clinic's approach to the planning system. Within the maxillofacial surgical care panorama, virtual technology is currently used in implant treatment, orthognathic surgery, trauma treatment, and temporomandibular joint reconstruction. In some clinics, virtual planning is performed collaboratively by surgeons and biomedical engineers, which may streamline the process while improving precision and reproducibility. The continued use of CSP in single-jaw surgery may be explained by variations in cost and resource availability among clinics. In some settings, VSP may be more expensive when the planning process is outsourced to external providers rather than performed in-house. Consequently, the choice of planning method may depend on each institution's financial and logistical circumstances, with clinics often reserving VSP for more demanding cases. There is varying evidence on the cost-efficiency of VSP [ 15 , 16 ]. Results from our study indicate that VSP in bimaxillary surgery leads to shorter surgery time. However, further research is needed to investigate the associated costs for Swedish surgery units and to determine the extent to which VSP is cost-benefit efficient compared with CSP. Both planning time and surgery time likely depend on the surgeon’s experience and established workflow. Further studies are needed to estimate whether VSP or CSP is less time-consuming. Overall, this study's findings suggest that VSP utilization by surgery type is influenced by surgical complexity. However, other factors, such as economic, logistical, and time-related considerations, may vary across clinical environments and influence decision-making. Sex The results indicate that sex does not influence the choice of planning method. Men and women had comparable proportions of virtual and conventional planning, and the difference was not significant ( p = 0.199). This suggests that the adoption of VSP is likely driven by other factors. Intraoperative blood loss Intraoperative blood loss varied between CSP and VSP during bimaxillary surgeries but not for single-jaw surgeries. Greater VSP use was associated with lower blood loss (200 ml) compared with CSP, which was more prevalently used in surgeries with blood loss ≥ 200 ml. A possible explanation is the precision of VSP and shorter surgery time. A potential confounding factor is the use of anticoagulants, which may have influenced intraoperative blood loss. Some clinics routinely administer anticoagulants during surgery, whereas others do not. Further investigation is needed to evaluate the relationship between planning method and intraoperative blood loss. Surgery time In bimaxillary surgeries VSP use was associated with a shorter surgery duration compared with CSP (Table 1 ). VSP may provide the surgeon with better preoperative visualization of skeletal movement, enhance splint accuracy, and reduce intraoperative adjustments, thereby improving workflow and reducing surgical inefficiency. A longer surgery time with CSP indicates that the method may lead to lower intraoperative efficiency. Error propagation may be easier with minor model error, less preoperative visualization, and greater intraoperative modifications, which cumulatively lead to extended surgical duration. Shorter surgery time is clinically desired because of the general association with lower complication rates, including excessive intraoperative blood loss. Trends in the utilization of virtual surgical planning Several factors may explain the significant increase in VSP utilization observed during the study period. The introduction of VSP computer systems to Swedish maxillofacial surgeons in 2017 likely attracted early adopters and stimulated initial growth. Implementing VSP at a surgical clinic requires access to intraoral scanners, specialized computers, a CBCT or CT machine, and support from an IT department connected to the clinic. These requirements entail additional financial investments, which may limit adoption at some clinics. However, further studies are needed to assess the actual cost-effectiveness of VSP. Moreover, individual surgeons’ preferences, experience, and interest in digital planning technologies may influence the extent of VSP use. Collectively, these factors may account for the subsequent plateau in VSP adoption. We observed a substantial decline in orthognathic surgeries performed with both CSP and VSP in 2020 and 2021, which correlates with the COVID-19 pandemic and indicates a significant impact on elective surgical procedures during this period (Fig. 3 ). The pandemic may also have contributed to the subsequent stagnation in VSP utilization. As clinics prioritized catching up on postponed surgeries and restoring surgical volumes, the introduction of new workflows, such as VSP, may have been deprioritized. Adopting a new planning system requires time for training and adaptation, and a temporary reduction in productivity is often inevitable during the learning phase. Therefore, these organizational and practical factors could have further delayed the continued expansion of VSP after the pandemic. Limitations The risk of confounding and selection bias should be considered in a retrospective cohort study without randomization. Given that participants were not randomly allocated to the surgical planning methods, there may be systematic differences between them that could have influenced the results. The potential confounding due to differences in surgery type groups was mitigated by dividing surgery time and intraoperative blood loss into single-jaw surgery and bimaxillary surgery groups. A surgeon's choice of planning method may potentially be influenced by preferences for a more traditional or modern approach, confidence in handling complex cases with one method or another, access, or familiarity. This can potentially lead to performance bias if a surgeon, for some reason, chooses only one method. Another surgeon-related confounding factor might be underreporting surgeries to NROK, as they are not obligated to do so. Although we cannot eliminate underreporting, the large data sample reduces its possible impact. Future research Clinical decision-making and adoption could be studied through a national survey, which could provide valuable insights into why different clinics choose to adopt or abstain from using VSP. This study did not include a cost comparison between VSP and CSP, but it is still important to consider not only how well a method works clinically but whether it is cost-effective. Data from NROK may be used for further studies on the cost-effectiveness of the two planning methods. As digital workflows continue to evolve, user-friendliness and automation are improving rapidly. The integration of artificial intelligence (AI) into surgical planning might further accelerate the process. Future studies could investigate how AI-assisted planning tools influence both efficiency and clinical outcomes. CONCLUSION This study demonstrated a significant increase in the adoption of VSP among Swedish maxillofacial surgical units between 2017 and 2024, particularly in planning bimaxillary surgeries compared to single-jaw surgeries. In addition, VSP may reduce intraoperative bleeding and shorten surgery time in bimaxillary surgeries compared with the use of CSP. STATEMENTS & DECLARATIONS Acknowledgments We extend our appreciation to Björn Tavelin for help with the statistical analysis. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Mats Sjöström was responsible for submitting the ethical review application, data collection, and supervising the project. Both Maria Spändbåge and Helena Stureson were responsible for statistical analysis, writing the manuscript, and constructing Table 1 and Figures 1, 2, and 3. Esmeralda Bäckström assisted in organizing the dataset, supported the interpretation of the statistical analyses, and provided general research assistance throughout the project. All authors discussed the results, commented on the manuscript, and agreed on the final version to be published. Ethics approval and Consent to participate The study was approved by the Swedish Ethical Review Authority in Uppsala, Sweden (Dnr: 2024-03098-02) and the ethics committee at the Department of Odontology, Umeå University. Data from NROK were approved on September 18, 2024, by Quality Register Västra Götalandsregionen (Dnr: RS 2024-04111). NROK obtained informed consent from all individual participants included in the study. Patient data, including diagnoses, treatments, and outcomes, were collected from NROK to improve and ensure healthcare quality in compliance with the General Data Protection Regulation (GDPR) and Chapter Seven of the Swedish Patient Data Act. Participation was voluntary, and data were handled under strict confidentiality. Patients have extensive rights regarding access, correction, and deletion of their personal information. The obtained data were anonymized in coded form by the provider of the NROK research database. Consequently, individual patients cannot withdraw the data once it has been anonymized and released. The obtained material was handled in compliance with the Helsinki Declaration. As the study is based on registry data rather than direct clinical intervention with patients, the potential risks are considered very low in relation to the benefits. Although processing patient data may entail certain risks, anonymizing the data is expected to minimize the likelihood of exposing personal information. Consent to publish Not applicable. Clinical trial number Not applicable. Data availability The datasets generated and analyzed during the current study are not publicly available under the Swedish Journal Act but are available from the corresponding author upon reasonable request. References Posnick JC (2014) Orthognathic Surgery: Principles & Practice. 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Br J Oral Maxillofac Surg 57(4): 345–351. https://doi.org/10.1016/j.bjoms.2018.12.019 Additional Declarations No competing interests reported. Supplementary Files APPENDIXA.docx Cite Share Download PDF Status: Published Journal Publication published 20 Feb, 2026 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted Editorial decision: Revision requested 03 Jan, 2026 Reviews received at journal 16 Dec, 2025 Reviewers agreed at journal 16 Dec, 2025 Reviewers invited by journal 12 Dec, 2025 Editor assigned by journal 04 Dec, 2025 Submission checks completed at journal 04 Dec, 2025 First submitted to journal 27 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Spändbåge","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYJCCA1DaDETIgUUekKLFGCySQKRtYC2JDSASnxbd9rMPD/xgqMvjn9287cGPXzbp88MOPwTaYien24DD5DPpBgd7GA4XS9w5Vm7Y25eWu/F2mgFQS7Kx2QEcWg6kMRzgYTiQ2HAjx0yCt+dw7sbZCSAtBxK34dJy/hnDwT8MdYnzgVok//b8Tzecnf4Bv5YbaQyHeRiYEzcAtUjz/DiQIC+dQ8CWG88YDssYHC42vJFWbizbkGy4QTqn4ECCAR6/nE9j/vimoi5P7kbytodv/tjJy89O3/zhQ4WdHC4tEGAAjQjGNiD7AESEIIBoYfjDwCDfQFj1KBgFo2AUjCwAABeWaj+CuBVDAAAAAElFTkSuQmCC","orcid":"","institution":"Umeå University","correspondingAuthor":true,"prefix":"","firstName":"Maria","middleName":"","lastName":"Spändbåge","suffix":""},{"id":561072748,"identity":"396996e0-0b7b-4aee-b190-47809d54c9b2","order_by":1,"name":"Helena Stureson","email":"","orcid":"","institution":"Umeå 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09:08:01","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97112,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8225093/v1/52a9beb8c65c7c4f4467ded8.html"},{"id":98779513,"identity":"02bcd730-63b1-461d-bcd7-3280da753fd9","added_by":"auto","created_at":"2025-12-22 12:30:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":88008,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of data selection and exclusion\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8225093/v1/46b6a1c8b674af50d7ae83e7.png"},{"id":98750177,"identity":"f570ab03-13c4-48c4-b417-df5fc093c8f3","added_by":"auto","created_at":"2025-12-22 09:08:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":15115,"visible":true,"origin":"","legend":"\u003cp\u003eRelative utilization of conventional surgical planning (CSP) and virtual surgical planning (VSP) from 2017 to 2024\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8225093/v1/3a4420edd066566280c0169a.png"},{"id":98750179,"identity":"8878a21d-7aa5-49bc-9d0e-a3d3f10c098b","added_by":"auto","created_at":"2025-12-22 09:08:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":13327,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of surgeries performed with conventional surgical planning (CSP) and virtual surgical planning (VSP) annually from 2017 to 2024\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8225093/v1/a339796fb9abf763194c6dcf.png"},{"id":103251134,"identity":"479d7423-1ce5-48d5-b5b1-fc5f750e675d","added_by":"auto","created_at":"2026-02-23 16:04:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":893649,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8225093/v1/227b0826-7ed7-49d9-ae53-7ff0b113f018.pdf"},{"id":98750175,"identity":"909b0692-30ff-4275-a48b-58da80b74493","added_by":"auto","created_at":"2025-12-22 09:08:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17245,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXA.docx","url":"https://assets-eu.researchsquare.com/files/rs-8225093/v1/f2c87f3f9a550f22e90d395b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Virtual planning in orthognathic surgery among Swedish maxillofacial surgeons: a retrospective register-based cohort study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDentofacial deformities are abnormal proportions of the maxillomandibular complex that result in a strongly unfavorable occlusal relationship [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Such deformities lead to varying impairments of jaw function, with associated pain and temporomandibular disorders, negatively impacting masticatory function [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Nevertheless, psychological and aesthetic factors strongly influence the quality of life of patients with dentofacial deformities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOrthognathic surgery aims to establish favorable maxillofacial function, normalize facial harmony, and increase health-related quality of life [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The various indications for surgery include craniofacial deformities, such as cleft lip and palate, increased or reversed overjet, open bite, complete scissors bite, sleep apnea, and skeletal anomalies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBefore surgical correction, it is crucial to conduct a thorough analysis and develop a detailed plan for the surgical procedure to be performed using conventional surgical planning (CSP) or virtual surgical planning (VSP). CSP is performed with two-dimensional radiographs for cephalometric evaluation, plaster dental cast evaluation, and splint preparation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The method was designed before digitalization and is still widely used today. In contrast, VSP enables surgeons to create a virtual anatomical model of the patient's head and neck, incorporating facial soft tissue, underlying bone structures, and occlusion. A computed tomography (CT) or cone beam computed tomography (CBCT) image is imported into computer software to create a virtual three-dimensional (3D) model for planning [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The 3D model can also visualize potential postoperative outcomes and facilitate determining treatment options for the patient. Individualized wafers are manufactured using computer-aided design and computer-aided manufacturing [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The interocclusal relationship is obtained by using either a 3D surface scanner on traditional cast models of the patient's teeth or an intraoral scanner directly on the patient\u0026rsquo;s teeth [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDepending on the desired outcome, different surgical techniques are used on both the maxilla and mandible, often foregoing orthodontic treatment and, not uncommonly, are some orthodontics continuing after surgery for final adjustments [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In Sweden, Le Fort I osteotomy is the most common maxillary osteotomy. In the mandible sagittal split osteotomy in the mandible is the most common osteotomy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], usually performed bilaterally. In cases of extensive deviations between the dental arches, osteotomies are performed on both the maxilla and mandible, referred to as bimaxillary surgery.\u003c/p\u003e \u003cp\u003eThe average prevalence rate of orthognathic procedures between 2010 and 2014 was reported to be 6.3 per 100 000 persons, with 39.4% of patients undergoing bimaxillary surgery, and the mean age at the time of surgery was 22 years [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The first Swedish quality registry for orthognathic surgery (NROK) started in 2017, achieving 91% coverage and good adherence [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Of the 25 maxillofacial surgery units in Sweden that perform orthognathic surgery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], 18 are affiliated with NROK. The NROK receives approximately 900 to 1 000 new registrations annually.\u003c/p\u003e \u003cp\u003eOrthognathic surgery is generally considered a safe procedure with a very low incidence of complications. However, both intraoperative and postoperative complications can occur. These complications, including surgical blood loss, neurosensory deficits of the inferior alveolar nerve, temporomandibular joint issues, relapse, and local irritation or infection related to osteosynthesis materials, can range from mild to severe [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe recent literature presents conflicting evidence regarding whether VSP or CSP is more cost-effective and less time-consuming. One study indicated that VSP is significantly more cost-effective than CSP in bimaxillary surgery considering reduced preoperative laboratory work, shorter surgery time, and lower planning costs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Another highlighted the disadvantages of VSP, including the cost of CBCT scans and software, as well as longer planning time [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The average planning time for CSP was reported to be 20 minutes per patient, whereas VSP required 38 minutes on average [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, over the 1-year evaluation period, planning time with VSP decreased as experience increased, highlighting a learning curve [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe techniques demonstrate comparable accuracy in predicting hard-tissue outcomes, but VSP exhibits superior accuracy in predicting soft-tissue outcomes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Though both methods have been reported to effectively achieve sagittal correction and high patient satisfaction with results, patients operated on with VSP had better midline alignment, less occlusal plane misalignment, and more balanced ramus inclination, and a greater proportion of patients reported being \u0026ldquo;very satisfied\u0026rdquo; with the outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Surgeons also reported achieving more desirable results with VSP, particularly in terms of mandibular contour symmetry [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, studies have shown that VSP provides greater accuracy in predicting anterior maxillary outcomes and offers advantages when planning for correction of facial asymmetry despite both CSP and VSP demonstrating strong overall predictive capabilities for facial outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Notably, improvements in facial aesthetics have been observed in patients regardless of the planning method [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth CSP and VSP are currently used for planning orthognathic surgery, but knowledge of their actual use in Sweden remains limited. Despite studies suggesting potential advantages of VSP in surgical precision, patient satisfaction, and cost-effectiveness, its adoption across surgical units and temporal trends remain largely unexplored. By analyzing these patterns, we aim to contribute to clinical decision-making, resource use, and favorable patient outcomes, as well as increasing understanding the impact of digitalization in surgical planning on efficiency and accuracy, thereby improving patient care for those with dentofacial deformities.\u003c/p\u003e \u003cp\u003eThis retrospective register-based cohort study aimed to provide a descriptive statistical analysis of orthognathic surgeries in Sweden between 2017 and 2024. The primary objective was to evaluate the use of CSP and VSP among Swedish oral and maxillofacial surgical units that perform orthognathic surgery and to investigate potential temporal trends in their use. The hypothesis was that VSP is more frequently used during bimaxillary surgery. The study also aimed to evaluate the number of included patients, sex distribution, mean surgery time, intraoperative blood loss, and mean age at the time of surgery, as well as provide a descriptive analysis of the numbers of single-jaw and bimaxillary surgeries.\u003c/p\u003e"},{"header":"MATERIALS \u0026 METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and data selection\u003c/h2\u003e \u003cp\u003eIn October 2024, NROK provided an anonymized dataset consisting of 2 755 sequence numbers registered from 2017 to 2024. Each unique sequence number corresponds to a patient and serves as an anonymized identifier to evaluate individual patient data without compromising patient confidentiality. The sequence numbers were reviewed for inclusion according to predefined criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFirst, entries associated with craniofacial syndromes or developmental anomalies were removed. A total of 307 diagnostic labels meeting the exclusion criteria were identified; 37 patients had more than one diagnosis recorded and were counted only once. Thus, this categorization represented 270 unique patients who were excluded from the study population.\u003c/p\u003e \u003cp\u003eNext, surgery types linked to excluded diagnoses, patients who underwent only genioplasty, and duplicate registrations were excluded. Duplicate entries were identified as the same sequence number appearing in multiple rows in the dataset, indicating that some patients had undergone orthognathic surgery on more than one occasion during the study period. Only the first recorded surgery per patient was included to ensure that each patient contributed only one observation to the analysis and to avoid overrepresentation of individuals with repeated procedures. In addition, 12 patients had no recorded surgery type data, possibly due to our exclusion criteria for the NROK dataset. These patients were not included in the statistical analysis.\u003c/p\u003e \u003cp\u003eAfter applying all exclusion criteria and removing duplicates and entries missing surgery type, 2 386 sequence numbers remained for analysis. These were categorized (see Appendix A) into maxillary surgery (n\u0026thinsp;=\u0026thinsp;562), mandibular surgery (n\u0026thinsp;=\u0026thinsp;742), and bimaxillary surgery (n\u0026thinsp;=\u0026thinsp;1 082).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics (version 28.0, IBM Corp, Armonk, NY, USA). Cross-tabulation was used to analyze potential patterns and correlations for CSP and VSP, as well as the variables used in this study. The significance level was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eA Pearson chi-squared test was used to assess the significance of differences between CSP and VSP for the variables of interest. The variables of interest were the number of surgeries, number of surgery types (maxillary, mandibular, and bimaxillary), patient sex, intraoperative blood loss (divided into single-jaw and bimaxillary surgery groups; \u0026lt;200 ml, 200\u0026ndash;500 ml, \u0026gt;\u0026thinsp;500 ml), and surgery time (divided into single-jaw and bimaxillary surgery groups; \u0026lt;2 h, 2\u0026ndash;4 h, 4\u0026ndash;6 h, \u0026gt;\u0026thinsp;6 h).\u003c/p\u003e \u003cp\u003eSixty-seven patients with no intraoperative blood loss data recorded and 32 patients with no surgery time data recorded were excluded from the statistical analyses of those variables.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive statistics\u003c/h2\u003e \u003cp\u003eThe final sample consisted of 2 386 patients, including 1 109 (46.5%) males and 1 277 (53.5%) females ranging in age from 15 to 71 years, with a mean age of 24.05 years at the time of surgery. Of these 2 386 patients, 1 440 (60.4%) underwent surgery with CSP and 946 (39.6%) with VSP. The descriptive statistics and analysis are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics and analysis of the included data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVariable of interest\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCSP, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eVSP, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eTotal, n (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP-value*\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e448 (31.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e562 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e594 (41.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e148 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e742 (31.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBimaxillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e398 (27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e684 (72.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 082 (45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 440 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e946 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 386 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e654 (45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e455 (48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 109 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e786 (54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e491 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 282 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 451 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e947 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 398 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss, single-jaw surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;200 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e663 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e844 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e200\u0026ndash;500 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e329 (32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e402 (31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;500 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 006 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e260 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 266 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss, bimaxillary surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;200 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e203 (30.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e273 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e200\u0026ndash;500 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e242 (63.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e409 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e651 (61.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;500 ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e129 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e379 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e674 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 053 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery time, single-jaw\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e553 (53.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129 (49.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e682 (53.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;4 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e462 (45.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125 (48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e587 (45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;6 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 026 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e260 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 286 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery time, bimaxillary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;4 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248 (64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e510 (74.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e758 (71.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135 (19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e242 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;6 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e387 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e681 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 068 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eCSP, conventional surgical planning; VSP, virtual surgical planning. *Pearson chi-squared test.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgery type\u003c/h3\u003e\n\u003cp\u003eThe analysis revealed a significant difference between the type of surgery performed and the planning method (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). VSP was predominantly used for bimaxillary surgery (72.3%), and CSP was primarily used for single-jaw surgery, both maxillary (31.1%) and mandibular (41.3%).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSex\u003c/h2\u003e \u003cp\u003eA comparison between sex and the utilization of VSP and CSP showed no significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.199). Male patients accounted for 45.4% and female patients for 54.6% of the CSP group. In the VSP group, the sex distribution was 48.1% males and 51.9% females.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBleeding\u003c/h3\u003e\n\u003cp\u003eDistribution analysis of intraoperative blood loss during single-jaw surgeries showed no significant difference between CSP and VSP (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.223). However, a significant difference was observed between CSP and VSP the bimaxillary surgery groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). For intraoperative blood loss, the CSP group showed that 18.5% of patients lost\u0026thinsp;\u0026lt;\u0026thinsp;200 ml, 63.9% lost 200\u0026ndash;500 ml, and 17.7% lost\u0026thinsp;\u0026gt;\u0026thinsp;500 ml. In comparison, the VSP group demonstrated 30.1% with \u0026lt;\u0026thinsp;200 ml blood loss, 60.7% with 200\u0026ndash;500 ml, and 9.2% with \u0026gt;\u0026thinsp;500 ml. Thus, the CSP group had a higher proportion of patients with major blood loss (\u0026gt;\u0026thinsp;500 ml), whereas the VSP group had a larger proportion with low blood loss (\u0026lt;\u0026thinsp;200 ml).\u003c/p\u003e\n\u003ch3\u003eSurgery time\u003c/h3\u003e\n\u003cp\u003eSingle-jaw surgeries were generally completed in under 2 hours, while most bimaxillary procedures required 2\u0026ndash;4 hours. Surgery time for single-jaw procedures was not significantly different between CSP and VSP (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.124). In contrast, bimaxillary surgery time showed a significant difference between the groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the CSP group, 3.4% of surgeries lasted\u0026thinsp;\u0026lt;\u0026thinsp;2 hours, 64.1% lasted 2\u0026ndash;4 hours, 27.6% lasted 4\u0026ndash;6 hours, and 4.9% exceeded 6 hours. In the VSP group, 3.5% of surgeries lasted\u0026thinsp;\u0026lt;\u0026thinsp;2 hours, 74.9% lasted 2\u0026ndash;4 hours, 19.8% lasted 4\u0026ndash;6 hours, and 1.8% exceeded 6 hours. Bimaxillary surgeries planned with VSP demonstrated fewer procedures exceeding 6 hours and a higher proportion completed within 2\u0026ndash;4 hours compared to CSP.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTemporal trends of utilization of VSP and CSP\u003c/h2\u003e \u003cp\u003eWe observed a significant increase in the utilization of VSP between 2017 and 2024 compared to CSP (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). From 2017 to 2020, VSP use increased by 46.8 percentage points, from 3.4% to 50.2%, with an equivalent decrease in CSP use from 96.6% to 49.8%. From 2020 to 2024, the difference between planning methods plateaued.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe purpose of this register-based retrospective study was to compare VSP and CSP in orthognathic surgeries performed in Sweden between 2017 and 2024, focusing on general surgical parameters and usage trends. To the best of our knowledge, this study is the first to compare the utilization of VSP and CSP in orthognathic surgeries using systematically registered data from NROK.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBimaxillary vs. single-jaw surgery\u003c/h2\u003e \u003cp\u003eThis study demonstrates a significant association between planning method and surgery type, with VSP use being substantially more prevalent in bimaxillary surgeries. A likely explanation is that bimaxillary surgery generally involves greater technical complexity and, therefore, benefits from enhanced accuracy, visualization, and predictability provided by VSP. Another explanation can be attributed to the individual clinic's approach to the planning system. Within the maxillofacial surgical care panorama, virtual technology is currently used in implant treatment, orthognathic surgery, trauma treatment, and temporomandibular joint reconstruction. In some clinics, virtual planning is performed collaboratively by surgeons and biomedical engineers, which may streamline the process while improving precision and reproducibility.\u003c/p\u003e \u003cp\u003eThe continued use of CSP in single-jaw surgery may be explained by variations in cost and resource availability among clinics. In some settings, VSP may be more expensive when the planning process is outsourced to external providers rather than performed in-house. Consequently, the choice of planning method may depend on each institution's financial and logistical circumstances, with clinics often reserving VSP for more demanding cases. There is varying evidence on the cost-efficiency of VSP [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Results from our study indicate that VSP in bimaxillary surgery leads to shorter surgery time. However, further research is needed to investigate the associated costs for Swedish surgery units and to determine the extent to which VSP is cost-benefit efficient compared with CSP.\u003c/p\u003e \u003cp\u003eBoth planning time and surgery time likely depend on the surgeon\u0026rsquo;s experience and established workflow. Further studies are needed to estimate whether VSP or CSP is less time-consuming. Overall, this study's findings suggest that VSP utilization by surgery type is influenced by surgical complexity. However, other factors, such as economic, logistical, and time-related considerations, may vary across clinical environments and influence decision-making.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSex\u003c/h2\u003e \u003cp\u003eThe results indicate that sex does not influence the choice of planning method. Men and women had comparable proportions of virtual and conventional planning, and the difference was not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.199). This suggests that the adoption of VSP is likely driven by other factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative blood loss\u003c/h2\u003e \u003cp\u003eIntraoperative blood loss varied between CSP and VSP during bimaxillary surgeries but not for single-jaw surgeries. Greater VSP use was associated with lower blood loss (200 ml) compared with CSP, which was more prevalently used in surgeries with blood loss\u0026thinsp;\u0026ge;\u0026thinsp;200 ml. A possible explanation is the precision of VSP and shorter surgery time. A potential confounding factor is the use of anticoagulants, which may have influenced intraoperative blood loss. Some clinics routinely administer anticoagulants during surgery, whereas others do not. Further investigation is needed to evaluate the relationship between planning method and intraoperative blood loss.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSurgery time\u003c/h2\u003e \u003cp\u003eIn bimaxillary surgeries VSP use was associated with a shorter surgery duration compared with CSP (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). VSP may provide the surgeon with better preoperative visualization of skeletal movement, enhance splint accuracy, and reduce intraoperative adjustments, thereby improving workflow and reducing surgical inefficiency. A longer surgery time with CSP indicates that the method may lead to lower intraoperative efficiency. Error propagation may be easier with minor model error, less preoperative visualization, and greater intraoperative modifications, which cumulatively lead to extended surgical duration. Shorter surgery time is clinically desired because of the general association with lower complication rates, including excessive intraoperative blood loss.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTrends in the utilization of virtual surgical planning\u003c/h2\u003e \u003cp\u003eSeveral factors may explain the significant increase in VSP utilization observed during the study period. The introduction of VSP computer systems to Swedish maxillofacial surgeons in 2017 likely attracted early adopters and stimulated initial growth. Implementing VSP at a surgical clinic requires access to intraoral scanners, specialized computers, a CBCT or CT machine, and support from an IT department connected to the clinic. These requirements entail additional financial investments, which may limit adoption at some clinics. However, further studies are needed to assess the actual cost-effectiveness of VSP. Moreover, individual surgeons\u0026rsquo; preferences, experience, and interest in digital planning technologies may influence the extent of VSP use. Collectively, these factors may account for the subsequent plateau in VSP adoption.\u003c/p\u003e \u003cp\u003eWe observed a substantial decline in orthognathic surgeries performed with both CSP and VSP in 2020 and 2021, which correlates with the COVID-19 pandemic and indicates a significant impact on elective surgical procedures during this period (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The pandemic may also have contributed to the subsequent stagnation in VSP utilization. As clinics prioritized catching up on postponed surgeries and restoring surgical volumes, the introduction of new workflows, such as VSP, may have been deprioritized. Adopting a new planning system requires time for training and adaptation, and a temporary reduction in productivity is often inevitable during the learning phase. Therefore, these organizational and practical factors could have further delayed the continued expansion of VSP after the pandemic.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe risk of confounding and selection bias should be considered in a retrospective cohort study without randomization. Given that participants were not randomly allocated to the surgical planning methods, there may be systematic differences between them that could have influenced the results. The potential confounding due to differences in surgery type groups was mitigated by dividing surgery time and intraoperative blood loss into single-jaw surgery and bimaxillary surgery groups. A surgeon's choice of planning method may potentially be influenced by preferences for a more traditional or modern approach, confidence in handling complex cases with one method or another, access, or familiarity. This can potentially lead to performance bias if a surgeon, for some reason, chooses only one method. Another surgeon-related confounding factor might be underreporting surgeries to NROK, as they are not obligated to do so. Although we cannot eliminate underreporting, the large data sample reduces its possible impact.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFuture research\u003c/h2\u003e \u003cp\u003eClinical decision-making and adoption could be studied through a national survey, which could provide valuable insights into why different clinics choose to adopt or abstain from using VSP. This study did not include a cost comparison between VSP and CSP, but it is still important to consider not only how well a method works clinically but whether it is cost-effective. Data from NROK may be used for further studies on the cost-effectiveness of the two planning methods.\u003c/p\u003e \u003cp\u003eAs digital workflows continue to evolve, user-friendliness and automation are improving rapidly. The integration of artificial intelligence (AI) into surgical planning might further accelerate the process. Future studies could investigate how AI-assisted planning tools influence both efficiency and clinical outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study demonstrated a significant increase in the adoption of VSP among Swedish maxillofacial surgical units between 2017 and 2024, particularly in planning bimaxillary surgeries compared to single-jaw surgeries. In addition, VSP may reduce intraoperative bleeding and shorten surgery time in bimaxillary surgeries compared with the use of CSP.\u003c/p\u003e"},{"header":"STATEMENTS \u0026 DECLARATIONS","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our appreciation to Björn Tavelin for help with the statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Mats Sjöström was responsible for submitting the ethical review application, data collection, and supervising the project. Both Maria Spändbåge and Helena Stureson were responsible for statistical analysis, writing the manuscript, and constructing Table 1 and Figures 1, 2, and 3. Esmeralda Bäckström assisted in organizing the dataset, supported the interpretation of the statistical analyses, and provided general research assistance throughout the project. All authors discussed the results, commented on the manuscript, and agreed on the final version to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Swedish Ethical Review Authority in Uppsala, Sweden (Dnr: 2024-03098-02) and the ethics committee at the Department of Odontology, Umeå University. Data from NROK were approved on September 18, 2024, by Quality Register Västra Götalandsregionen (Dnr: RS 2024-04111).\u003c/p\u003e\n\u003cp\u003eNROK obtained informed consent from all individual participants included in the study. Patient data, including diagnoses, treatments, and outcomes, were collected from NROK to improve and ensure healthcare quality in compliance with the General Data Protection Regulation (GDPR) and Chapter Seven of the Swedish Patient Data Act. Participation was voluntary, and data were handled under strict confidentiality. Patients have extensive rights regarding access, correction, and deletion of their personal information. The obtained data were anonymized in coded form by the provider of the NROK research database. Consequently, individual patients cannot withdraw the data once it has been anonymized and released. The obtained material was handled in compliance with the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003eAs the study is based on registry data rather than direct clinical intervention with patients, the potential risks are considered very low in relation to the benefits. Although processing patient data may entail certain risks, anonymizing the data is expected to minimize the likelihood of exposing personal information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available under the Swedish Journal Act but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePosnick JC (2014) Orthognathic Surgery: Principles \u0026amp; Practice. Elsevier, St. Louis\u003c/li\u003e\n\u003cli\u003eMadhan S, Nascimento GG, Ingerslev J, Cornelis M, Pinholt EM, Cattaneo PM, Svensson P (2023) Associations between temporomandibular disorders, pain, jaw and masticatory function in dentofacial deformity patients: a cross-sectional study. J Oral Rehabil 50:746\u0026ndash;757. https://doi.org/10.1111/joor.13483\u003c/li\u003e\n\u003cli\u003eMendes de Paula Gomes A, Adas Saliba Garbin C, da Silva Ferraz FW, Adas Saliba T, Isper Garbin AJ (2019) Dentofacial deformities and implications on quality of life: a presurgical multifactorial analysis in patients seeking orthognathic surgical treatment. J Oral Maxillofac Surg 77:409.e1\u0026ndash;409.e9. https://doi.org/10.1016/j.joms.2018.09.023\u003c/li\u003e\n\u003cli\u003eJohansson E, Lund B, Bengtsson M, Magnusson M, Rasmusson L, Ahl M, Sunzel B (2024) Quality of life after orthognathic surgery in Swedish patients: a register-based cohort. Clin Exp Dent Res 10:e942. https://doi.org/10.1002/cre2.942\u003c/li\u003e\n\u003cli\u003eBengtsson M, Wall G, Larsson P, Becktor JP, Rasmusson L (2018) Treatment outcomes and patient-reported quality of life after orthognathic surgery with computer-assisted 2- or 3-dimensional planning: a randomized double-blind active-controlled clinical trial. Am J Orthod Dentofacial Orthop 153:786\u0026ndash;796. https://doi.org/10.1016/j.ajodo.2017.12.008\u003c/li\u003e\n\u003cli\u003eMadhan S, Nascimento GG, Ingerslev J, Cornelis M, Pinholt EM, Cattaneo PM, Svensson P (2024) Health-related quality of life, jaw function and sleep-disordered breathing among patients with dentofacial deformity. J Oral Rehabil 51:684\u0026ndash;694. https://doi.org/10.1111/joor.13619\u003c/li\u003e\n\u003cli\u003eIreland AJ, Cunningham SJ, Petrie A, Cobourne MT, Acharya P, Sandy JR, Hunt NP (2014) An index of orthognathic functional treatment need (IOFTN). J Orthod 41:77\u0026ndash;83. https://doi.org/10.1179/1465313314Y.0000000100\u003c/li\u003e\n\u003cli\u003eRasmusson L (2021) Orthognathic surgery with 3D virtual surgical planning. In: Nordic Textbook of Oral and Maxillofacial Surgery. Munksgaard, Copenhagen, Chap 26\u003c/li\u003e\n\u003cli\u003eSwennen GRJ, Mollemans W, Schutyser F (2009) Three-dimensional treatment planning of orthognathic surgery in the era of virtual imaging. J Oral Maxillofac Surg 67:2080\u0026ndash;2092. https://doi.org/10.1016/j.joms.2009.06.007\u003c/li\u003e\n\u003cli\u003eHo CT, Lin HH, Lo LJ (2019) Intraoral scanning and setting up the digital final occlusion in three-dimensional planning of orthognathic surgery: its comparison with the dental model approach. Plast Reconstr Surg 143:1027e\u0026ndash;1036e. https://doi.org/10.1097/PRS.0000000000005556\u003c/li\u003e\n\u003cli\u003eTorres Romero SD, Bacilio Villon BA, Montenegro Benavides JV, Rosero Quinche TE (2024) Integrating orthodontic and maxillofacial surgical approaches for correction of complex dentofacial deformities: a comprehensive literature review. Int J Med Sci Dent Health 10:131\u0026ndash;140. https://doi.org/10.55640/ijmsdh-10-08-12\u003c/li\u003e\n\u003cli\u003eSj\u0026ouml;str\u0026ouml;m M, Lund B, Sunzel B, Bengtsson M, Magnusson M, Rasmusson L (2022) Starting a Swedish national quality registry for orthognathic surgery: a tool for auditing fundamentals of care. BMC Oral Health 22:588. https://doi.org/10.1186/s12903-022-02568-6\u003c/li\u003e\n\u003cli\u003eSt\u0026aring;lhand G, Abdiu A, Rasmusson L, Abtahi J (2023) Distribution of orthognathic surgery among the Swedish population: a retrospective register-based study. Acta Odontol Scand 81:414\u0026ndash;421. https://doi.org/10.1080/00016357.2022.2164352\u003c/li\u003e\n\u003cli\u003eFerri J, Druelle C, Schlund M, Bricout N, Nicot R (2019) Complications in orthognathic surgery: a retrospective study of 5025 cases. Int Orthod 17:789\u0026ndash;798. https://doi.org/10.1016/j.ortho.2019.08.016\u003c/li\u003e\n\u003cli\u003eResnick CM, Inverso G, Wrzosek M, Padwa BL, Kaban LB, Peacock ZS (2016) Is there a difference in cost between standard and virtual surgical planning for orthognathic surgery? J Oral Maxillofac Surg 74:1827\u0026ndash;1833. https://doi.org/10.1016/j.joms.2016.03.035\u003c/li\u003e\n\u003cli\u003eVan Hemelen G, Van Genechten M, Renier L, Desmedt M, Verbruggen E, Nadjmi N (2015) Three-dimensional virtual planning in orthognathic surgery enhances the accuracy of soft tissue prediction. J Craniomaxillofac Surg 43:918\u0026ndash;925. https://doi.org/10.1016/j.jcms.2015.04.006\u003c/li\u003e\n\u003cli\u003eWu TY, Lin HH, Lo LJ, Ho CT (2017) Postoperative outcomes of two- and three-dimensional planning in orthognathic surgery: a comparative study. J Plast Reconstr Aesthet Surg 70:1101\u0026ndash;1111. https://doi.org/10.1016/j.bjps.2017.04.012\u003c/li\u003e\n\u003cli\u003eUdomlarptham N, Lin CH, Wang YC, Ko EW (2018) Does two-dimensional vs. three-dimensional surgical simulation produce better surgical outcomes among patients with class III facial asymmetry? Int J Oral Maxillofac Surg 47:1022\u0026ndash;1031. https://doi.org/10.1016/j.ijom.2018.02.014\u003c/li\u003e\n\u003cli\u003eBengtsson M, Wall G, Miranda-Burgos P, Rasmusson L (2017) Treatment outcome in orthognathic surgery - a prospective comparison of accuracy in computer-assisted two- and three-dimensional prediction techniques. J Craniomaxillofac Surg 46:1867\u0026ndash;1874. https://doi.org/10.1016/j.jcms.2017.01.035\u003c/li\u003e\n\u003cli\u003eBengtsson M, Wall G, Greiff L, Rasmusson L (2017) Treatment outcome in orthognathic surgery - a prospective randomized blinded case-controlled comparison of planning accuracy in computer-assisted two- and three-dimensional planning techniques (part II). J Craniomaxillofac Surg 45:1419\u0026ndash;1424. https://doi.org/10.1016/j.jcms.2017.07.001\u003c/li\u003e\n\u003cli\u003eBengtsson M, Al-Ateyah A, Wall G, Becktor JP, Rasmusson L (2019) Outcome of photographic evaluation of facial appearance in orthognathic surgery: how does it correlate with treatment planning and patient-reported outcome? Br J Oral Maxillofac Surg 57(4): 345\u0026ndash;351. https://doi.org/10.1016/j.bjoms.2018.12.019\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Orthognathic surgery, Virtual surgical planning, Conventional surgical planning, Three-dimensional surgical planning, Two-dimensional surgical planning","lastPublishedDoi":"10.21203/rs.3.rs-8225093/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8225093/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe integration of virtual surgical planning (VSP) into orthognathic surgery has improved preoperative visualization, surgical precision, and patient-specific outcomes. However, limited information is available regarding the utilization of VSP in Swedish maxillofacial clinics. This study primarily aimed to provide statistical analysis and descriptive statistics on orthognathic surgical parameters in Sweden between 2017 and 2024 and focused on comparing utilization between VSP and conventional surgical planning (CSP).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this retrospective register-based cohort study, statistical analyses were carried out using anonymized data from 2 386 non-syndrome associated patients registered in the Swedish National Registry for Orthognathic Surgery during the years 2017 to 2024.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe use of VSP among Swedish oral and maxillofacial surgeons significantly increased during the study period. A significant difference was found (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between VSP and CSP regarding surgery type, intraoperative blood loss for bimaxillary surgery, and surgery time for bimaxillary surgery. VSP is predominantly used in bimaxillary surgery, whereas CSP is more commonly used in single-jaw surgery.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings of this study demonstrate a significant increase in the adoption of VSP among Swedish maxillofacial surgical units between 2017 and 2024, particularly in planning bimaxillary surgeries compared to single-jaw surgeries. In addition, VSP may reduce intraoperative bleeding and shorten surgery time in bimaxillary surgeries compared with CSP.\u003c/p\u003e","manuscriptTitle":"Virtual planning in orthognathic surgery among Swedish maxillofacial surgeons: a retrospective register-based cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:07:56","doi":"10.21203/rs.3.rs-8225093/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-03T14:51:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T09:33:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273138376251308699465662721832131398808","date":"2025-12-16T07:56:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T09:46:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-04T08:04:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-04T08:03:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Oral and Maxillofacial Surgery","date":"2025-11-27T21:33:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"300a5971-876c-4af6-933d-556e7d6deb3b","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:01:44+00:00","versionOfRecord":{"articleIdentity":"rs-8225093","link":"https://doi.org/10.1007/s10006-026-01524-w","journal":{"identity":"oral-and-maxillofacial-surgery","isVorOnly":false,"title":"Oral and Maxillofacial Surgery"},"publishedOn":"2026-02-20 15:58:15","publishedOnDateReadable":"February 20th, 2026"},"versionCreatedAt":"2025-12-22 09:07:56","video":"","vorDoi":"10.1007/s10006-026-01524-w","vorDoiUrl":"https://doi.org/10.1007/s10006-026-01524-w","workflowStages":[]},"version":"v1","identity":"rs-8225093","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8225093","identity":"rs-8225093","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}