Int. J. Oral Maxillofac. Surg.

2022; 51: 1188–1196

https://doi.org/10.1016/j.ijom.2022.03.007, available online at https://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

M.B. Holte a,b, A. Diaconu a,

Virtual surgical analysis: long- J. Ingerslev c, J.J. Thorn c,
E.M. Pinholt a,b,c

term cone beam computed a

3D Lab Denmark, Department of Oral and
Maxillofacial Surgery, University Hospital of

tomography stability assessment Southern Denmark, Esbjerg, Denmark;

b
Department of Regional Health Research,
Faculty of Health Sciences, University of
Southern Denmark, Esbjerg, Denmark;

of segmental bimaxillary surgery c

Department of Oral and Maxillofacial
Surgery, University Hospital of Southern
Denmark, Esbjerg, Denmark

M. B. Holte, A. Diaconu, J. Ingerslev, J. J. Thorn, E. M. Pinholt: Virtual surgical

analysis: long-term cone beam computed tomography stability assessment of
segmental bimaxillary surgery. Int. J. Oral Maxillofac. Surg. 2022; 51:
1188–1196. © 2022 The Author(s). Published by Elsevier Inc. on behalf of
International Association of Oral and Maxillofacial Surgeons. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/
4.0/).

Abstract. The assessment of the stability of orthognathic surgery is often time-

consuming, relies on manual re-identification of anatomical landmarks, and has
been based on short-term follow-up. The purpose of this study was to propose
and validate a semi-automated approach for three-dimensional (3D) assessment
of the long-term stability of segmental bimaxillary surgery. The approach was
developed and validated using cone beam computed tomography scans obtained
at 2 weeks and 2 years postoperative. The stability of the surgical outcome was
calculated as 3D translational and rotational differences between the short- and
long-term postoperative positions of the individual bone segments. To evaluate
reliability, intra-class correlation coefficients were calculated at a 95%
confidence interval on measurements of two observers. Ten class II and III
patients (six male, four female; mean age 24.4 years), who underwent a
combined three-piece Le Fort I osteotomy, bilateral sagittal split osteotomy, and
genioplasty, were included in the study. Intra- and inter-observer reliability were Keywords: orthognathic surgery; computer-as­
sisted surgery; three-dimensional imaging;
excellent (range 0.82–0.99). The range of the mean absolute difference of the
maxillary osteotomy; mandibular osteotomy;
intra- and inter-observer translational and rotational measurements were genioplasty.
0.14 mm (0.13)–0.44 mm (0.50) and 0.20° (0.16)–0.92° (0.78). The approach has
excellent reliability for 3D assessment of long-term stability of segmental Accepted for publication 7 March 2022
bimaxillary surgery. Available online 26 March 2022

Introduction
This study is a continuation of the va­ dimensional (3D) approach for virtual proposed and validated. The approach
lidation study by Holte et al.1 In this surgical analysis (VSA) of the accuracy was solely validated on postoperative
previous work, a semi-automated three- of segmental bimaxillary surgery was cone beam computed tomography

0901-5027/511188 + 9 © 2022 The Author(s). Published by Elsevier Inc. on behalf of International Association of Oral and Maxillofacial
Surgeons. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

(CBCT) scans acquired immediately (2
weeks) after surgery. The purpose of
the present study was to expand and
validate the semi-automated VSA ap­
proach proposed by Holte et al.1 for 3D
assessment of the long-term (2-year)
postoperative stability of orthognathic
surgery. Due to bone remodelling and
resorption, long-term assessment is in­
herently more difficult than short-term
assessment from CBCT scans acquired
immediately after surgery. Hence, the
validity of the VSA is not evident and it
may fail to produce valid results. This
continuation study is paramount for
future skeletal stability assessment of
orthognathic surgery using automated
approaches, ensuring the validity of
these results.
Skeletal stability following orthog­
nathic surgery may be influenced by an
insufficient and inaccurate surgical ap­
proach, deficient pre- and postoperative
orthodontics, inefficient fixation of
bone segments, extent of the surgical
movement, surgical complications,
condition of the temporomandibular
joints, and masticatory muscle ac­
tivity.2,3
In a systematic review and meta-
analysis on treatment relapse in skeletal
class II patients, Gaitan-Romero et al.4
concluded that the outcomes of the
meta-analysis were limited due to the
heterogeneity of the data, small number
of studies, and inconsistent methods of
evaluation. Hence, further high-quality
studies utilizing standardized 3D
methodologies are required to improve
the level of evidence.
Most of the proposed methods for
3D assessment of the postoperative
outcome of orthognathic surgery and
accuracy of virtual surgical planning
(VSP) are based on cephalometric
analysis, where anatomical landmarks
are placed and re-identified to measure
bony movements.5–8 Landmark re-
identification errors have been shown
to range from 0.02 mm to 2.47 mm.9–12
The error may exceed the clinically re­
levant 0.5 mm margin,13,14 and even the
clinically acceptable surgical accuracy
and stability of 2 mm.4,8 Consequently,
image registration techniques have been
introduced for the superimposition of
two consecutive uni- or multimodal
scans based on a reference structure
using mutual image information,13–21
i.e. voxel-based registration (VBR),22–24
hence making the re-identification of
landmarks superfluous. A recent sys­
tematic review on protocols to assess
the outcomes of orthognathic surgery,
Segmental bimaxillary surgery stability assessment
showed that voxel-based super­
imposition protocols presented the
highest accuracy and reproducibility,
and protocols that used automated
processes and involved only one soft­
ware were the most efficient.25
A versatile and semi-automated ap­
proach using VBR for virtual 3D as­
sessment of the accuracy of segmental
bimaxillary surgery, including seg­
mental osteotomies, such as the three-
piece Le Fort I osteotomy, bilateral
sagittal split osteotomy (BSSO), and
genioplasty, was proposed and vali­
dated by Holte et al.1 The VSA ap­
proach is semi-automated as it solely
requires user input for VBR, com­
prising pre-alignment and selection of
the volume of interest (VOI). The
strength of the method by Holte et al.
was proven in the validation, which
showed excellent intra- and inter-ob­
server reliability (intra-class correlation
coefficient (ICC) > 0.96) and low mean
absolute difference of repeated intra-
and inter-observer translational
(< 0.20 mm) and rotational (< 0.63°)
measurements of all individual bone
segments.1 However, its applicability
and validity for 3D assessment of long-
term postoperative stability of seg­
mental bimaxillary surgery is not yet
proven. Mutual image information of
long-term postoperative CBCT scans
used for the registration of the in­
dividual bone segments is less similar
due to bone remodelling processes and
the continuous post-surgical ortho­
dontic treatment. This subsequently
affects the performance of the VSA,
and hence needs to be evaluated. The
VSA is hypothesized to be reliable for
long-term stability assessment if the
ICC is excellent (ICC > 0.80).26,27
Materials and methods
The VSA approach of Holte et al.1 was
expanded for the assessment of the
long-term stability of segmental bi­
maxillary surgical interventions. To
evaluate the intra- and inter-observer
reliability, two observers independently
applied the proposed VSA to analyse
the short-term (2 weeks) and long-term
(2 years) postoperative outcomes and
stability of the study sample. After a
minimum period of 2 weeks, one of the
observers, who was blinded to the in­
itial assessment, analysed the data
again.
The VSA expansion was designed to
meet the suggested criteria of Gaber
1189
et al.28: (1) applying VBR on the ante­
rior cranial base for registration and
alignment of the pre- and postoperative
scans to decrease the risk of human
error; (2) automated or semi-auto­
mated evaluation of the 3D transla­
tional and rotational outcomes; and (3)
validation of inter- and intra-observer
reliability.
Furthermore, the expansion was de­
signed to be (1) capable of 3D assess­
ment of the stability of bimaxillary
surgery, including segmental osteo­
tomies, such as the three-piece Le Fort
I osteotomy, BSSO, and genioplasty;
(2) achievable through a single software
suite; and (3) the user should also have
the option to use no cephalometric
landmarks or a preferred set of land­
marks, without the need for landmark
re-identification.
As this was a continuation of the
study by Holte et al.,1 please refer to
this previous work for details of the
study sample, image acquisition, sur­
gical planning and intervention, and
further technical details on the 3D as­
sessment. The previous study validated
the reliability of the proposed VSA to
assess the accuracy of virtually planned
segmental bimaxillary surgery and de­
monstrated excellent reliability. In the
present study, the reliability of the VSA
was validated for the assessment of the
long-term stability of segmental bi­
maxillary surgery.
Assessment of stability
The expansion of the semi-automated
VSA was programmed in Python 3.7
(Python Software Foundation,
Fredericksburg, VA, USA) and in­
tegrated into Mimics Innovation Suite
(Materialise NV, Leuven, Belgium)
using its scripting module. See Fig. 1
for a schematic overview.
Initially, the superimposition of
postoperative CBCT scans to the pre­
operative CBCT scan was performed
by VBR using the surgically unaffected
anterior cranial base, zygomatic arches,
and forehead as the VOI.16 Subse­
quently, the individual bone segments
were registered to their positions in the
short- and long-term postoperative
CBCT scans by VBR using the bone
segments as VOI. For registration on
the long-term postoperative scan, the
VOI were modified not to include areas
prone to interval changes, i.e. the teeth
of the dental segments due to post-
surgical orthodontics (Fig. 1). Conse­
quently, transformation matrices for
1190 Holte et al.

Fig. 1. Schematic overview of the virtual surgical analysis dataflow for 3D stability assessment using cone beam computed tomography
(CBCT). Voxel-based registration (VBR) on the anterior cranial base, followed by the regional bone segments with volume of interest
(VOI) boundary boxes.

the individual bone segments were cal­
culated and applied to transform du­
plicates of the bone segments and the
linked landmarks (optional) to the
postoperative positions. In this valida­
tion study, the landmarks in Table 1
were used.
The postoperative stability was cal­
culated as the translational (ante­
rior–posterior, right–left, and
superior–inferior) and rotational (pitch,
roll, and yaw) differences between the
short- and long-term postoperative
outcomes of the individual bone seg­
ments and the optional landmarks. The
assessment of the chin was performed
by adjusting for the postoperative
movement of the distal mandibular
segment. Colour-coded distance maps
were computed by part comparison in
order to present a quick overview of the
stability results.29 The colour range was
set to 0–2 mm, which is considered
clinically acceptable and stable in most
studies4 (Fig. 2).
Statistical analysis
The statistical analysis of the data was
performed in Stata 16.1 (StataCorp,
College Station, TX, USA). A sample
size calculation was performed for a one-
sample correlation study (ICC > 0.8,
power = 0.8, alpha = 0.05, and two
raters). The intra- and inter-observer re­
liability of measurements were summar­
ized using the mean absolute difference
(MAD) and standard deviation (SD).
For the two observers, intra-class
 Segmental bimaxillary surgery stability assessment 1191

Table 1. Definitions of optional 3D cephalometric landmarks.

Landmark Definition Bilateral
Maxillary landmarks
Anterior nasal spine (ANS) The most anterior midpoint of the anterior nasal spine of the maxilla
Upper incisors midpoint (UIM) The most mesial point of the tip of the crown in between the upper central
incisors
Upper canine (U3) The most inferior point of the tip of the crown of the upper canine R/L
Upper molar (U6) The most inferior point of the mesial buccal cusp of the crown of the first upper R/L
molar
Le Fort I osteotomy point (LF) The most anterior point on the Le Fort I osteotomy line at the distal root of the R/L
first upper molar
Mandibular landmarks
Lower incisors midpoint (LIM) The most mesial point of the tip of the crown between the lower central incisors
Lower canine (L3) The most superior point of the tip of the crown of the lower canine R/L
Lower molar (L6) The most superior point of the mesial buccal cusp of the crown of the lower R/L
molar
Pogonion (Pog) The most anterior midpoint of the chin on the outline of the mandibular
symphysis
Condylar hinge point (CH) The most superior posterior point on the mandibular condyle R/L
Gonion (Go) The most caudal, posterior, and lateral point of the mandibular angle R/L
R, right; L, left.

correlation coefficients were calculated at
a 95% confidence interval using a one-
way random-effects model for single
measurements. Bland–Altman plots were
used to evaluate observer agreement with
95% limits of agreement. The output of
the VSA, the postoperative stability, was
computed by the differences between the
short- and long-term postoperative out­
comes. Mean difference (MD), MAD,
and SD values were calculated to sum­
marize the differences.
Results
The statistical sample size calculation
resulted in a required sample size of n =
10 to obtain a statistical power of 0.8,
which is in accordance with previous
studies on surgical accuracy assess­
ment.1,13,19 Hence, the first 10 con­
secutive post-pubertal patients in 2019
(January–April) who met the inclusion
and exclusion criteria were included.
The patients were skeletal class II and
III, with symmetry/asymmetry, who
underwent maxillomandibular ad­
vancement or mandibular setback,
maxillary expansion, and genioplasty;
six were male and four female, and
their mean age was 24.4 years.
The intra- and inter-observer MAD,
SD, and ICC values are presented in
Supplementary Material Table S1
(Appendix A). The range of the intra-
and inter-observer ICCs of the post­
operative stability measurements were
0.91–0.99 and 0.82–0.99, respectively.
The range of the translational intra-
and inter-observer MAD (SD) of the
postoperative stability measurements
were 0.14 mm (0.13)–0.28 mm (0.25)
and 0.25 mm (0.22)–0.44 mm (0.50),
respectively. The range of the rota­
tional intra- and inter-observer MAD
(SD) of the postoperative stability
measurements were 0.20° (0.16)–0.63°
(0.63) and 0.23° (0.18)–0.92° (0.78), re­
spectively. The largest MAD results
were obtained for the rotational mea­
surements of the smallest bone seg­
ments: the chin and the central
maxillary segment.
Supplementary Material Table S2
(Appendix A) summarizes the data of
the Bland–Altman plots (available in
Supplementary Material Appendix B)
for further analysis of observer agree­
ment. The results showed low biases
(0.00–0.24 mm) and no systematic er­
rors. The range of the translational
intra- and inter-observer limits of
agreement were −0.37–0.36 mm to
−0.73–0.75 mm and −0.72–0.56 mm to
−1.43–1.13 mm, respectively. The range
of the rotational intra- and inter-ob­
server limits of agreement were
−0.51–0.51° to −1.86–1.61° and
−0.56–0.60° to −2.29–2.46°, respec­
tively. The narrow limits of agreement
show a high degree of consistency of
most measurements. Again, the rota­
tional measurements of the chin and
the central maxillary segment showed
the lowest degree of agreement.
To demonstrate the clinical applica­
tion and relevance of the proposed
VSA, the short- and long-term post­
operative outcomes of orthognathic
surgery were analysed and compared.
The stability, presented as translational
and rotational discrepancies in the
three dimensions, is summarized in
Table 2 and shown by the visual output
of the VSA in Supplementary Material
Fig. S1. All of the translational and
rotational MAD results were within the
clinically acceptable stability of 2 mm
and 4°, respectively.4 The largest
translational discrepancies were seen in
the superoinferior direction of the
proximal (1.58 mm (1.84)) and distal
(1.56 mm (0.86)) mandibular segments,
and the anteroposterior direction of the
central maxillary segment (1.52 mm
(1.13)). The largest rotational dis­
crepancies were seen in the flaring of
the maxillary segments (3.37° (3.43)), in
the pitch of the chin (2.68° (1.36)), and
in the distal (2.06° (1.24)) and proximal
(1.84° (1.83)) mandibular segments.
Discussion
The purpose of this study was to ex­
pand and validate the semi-automated
approach proposed by Holte et al.1 for
3D assessment of the long-term post­
operative stability of segmental bimax­
illary surgery. The expanded approach
was designed to meet the suggested
criteria of Gaber et al.28 (see Materials
and methods), and is capable of asses­
sing the 3D stability of bimaxillary
surgery, including segmental osteo­
tomies, such as the three-piece Le Fort
I osteotomy, BSSO, and genioplasty.
The 3D stability assessment is achiev­
able through a single software suite and
provides the user with the option to use
no cephalometric landmarks (land­
mark-free) or a preferred set of land­
marks, without the need for landmark
re-identification. This optimized
1192 Holte et al.

Fig. 2. Output of the virtual surgical analysis of postoperative stability.

 Segmental bimaxillary surgery stability assessment 1193

Table 2. Postoperative stability results for the three-dimensional assessment between the short- and long-term postoperative transla­
tional and rotational measurements; mean differences (MD), mean absolute differences (MAD), and standard deviations (SD).
Translational movements (mm) Rotational movements (°)
A(+) / P(−) R(+) / L(−) I(+) / S(−) Pitch Roll Yaw
Mandibular distal (LIM) MD (SD) −0.78 (1.35) 0.48 (0.97) 0.74 (1.68) 1.09 (2.23) 0.48 (0.90) −0.43 (1.02)
MAD (SD) 1.12 (1.05) 0.67 (0.84) 1.56 (0.86) 2.06 (1.24) 0.64 (0.78) 0.71 (0.83)
Proximal left (CHL) MD (SD) 0.25 (1.50) −0.83 (0.58) 0.13 (1.13) 0.29 (2.62) 1.40 (0.78) −0.03 (0.95)
MAD (SD) 0.85 (1.24) 0.87 (0.51) 0.86 (0.69) 1.58 (2.04) 1.40 (0.78) 0.68 (0.63)
Proximal right (CHR) MD (SD) 0.48 (1.70) −0.20 (1.18) −1.18 (2.15) 1.33 (2.27) −0.67 (1.11) −1.11 (1.33)
MAD (SD) 1.17 (1.28) 0.78 (0.87) 1.58 (1.84) 1.84 (1.83) 0.92 (0.89) 1.39 (1.00)
Chin (Pog) MD (SD) −0.36 (0.68) 0.06 (0.46) 1.18 (1.06) 1.60 (2.64) −0.26 (0.85) 0.17 (1.10)
MAD (SD) 0.65 (0.38) 0.39 (0.22) 1.19 (1.05) 2.68 (1.36) 0.64 (0.58) 0.88 (0.62)
Maxillary central (UIM) MD (SD) −1.52 (1.13) 0.24 (0.57) 0.64 (1.43) 2.82 (3.95) 0.84 (2.09) 0.08 (1.48)
MAD (SD) 1.52 (1.13) 0.51 (0.33) 1.16 (1.00) 3.37 (3.43) 1.87 (1.12) 1.22 (0.72)
Maxillary left (U3L) MD (SD) −0.14 (0.77) 1.29 (0.90) 0.77 (1.09) 0.10 (1.79) 3.15 (1.60) −0.44 (1.29)
MAD (SD) 0.58 (0.48) 1.39 (0.72) 1.12 (0.67) 1.30 (1.16) 3.15 (1.60) 1.12 (0.71)
Maxillary right (U3R) MD (SD) −0.40 (0.94) −1.08 (0.61) 0.98 (0.65) 1.13 (2.11) −2.34 (1.74) 0.03 (1.21)
MAD (SD) 0.68 (0.74) 1.08 (0.61) 1.02 (0.59) 2.03 (1.14) 2.36 (1.71) 1.00 (0.59)
A/P, anterior/posterior; R/L, right/left; I/S, inferior/superior; pitch (+), clockwise rotation in the right-sagittal view; roll (+), clockwise
rotation in the front-coronal view; yaw (+), clockwise rotation in the bottom-axial view.

approach for the assessment of the
long-term postoperative stability of
orthognathic surgery is novel and does
not appear to have been published be­
fore. The validation showed that the
VSA is reliable for 3D assessment of
the long-term postoperative stability.
The intra- and inter-observer reliability
were excellent.27 Hence the hypothesis
was met.
The stability measurements of the
smallest bone segments, the chin and
the maxillary segments, were the least
consistent (Supplementary Material
Tables S1 and S2; Appendix A). This
indicates that the VBR is more sensitive
to the registration of small volumes
with image artefacts caused by im­
plants, which are notoriously challen­
ging and should be reduced or avoided
in the VOI for VBR. This is similar to
the validation results for 3D assessment
of the surgical accuracy reported by
Holte et al.1 Furthermore, the transla­
tional stability measurements of the
proximal mandibular segments of pa­
tients with treatment relapse caused by
condylar displacements and resorption
showed more observer variability. In
these patients, not only was resorption
of the condyles present, but there was
also a high degree of ramal resorption
and remodelling. This indicates that the
entire proximal mandibular segment
may not be morphologically stable, and
therefore not optimal as a VOI for
VBR. Hence, applying a stable ramal
sub-region as the VOI for registration
may improve the reliability of the sta­
bility measurements of the proximal
mandibular segments. Due to the semi-
automation, the observer-dependent
variability is solely dependent on the
manual user input for VBR: the pre-
alignment and the selection of the VOI.
The difference between the intra- and
inter-observer reliability indicates that
the inter-observer variability can be
reduced by careful calibration.
To demonstrate the clinical applic­
ability and relevance of the proposed
VSA, the postoperative stability of the
study sample was assessed. To avoid
selection bias, severe asymmetry and
complex osteotomies, including bone
reduction and grafting, were not ex­
cluded in the patient selection. The
average translational and rotational
stability of the individual bone seg­
ments for the study sample, which even
presented treatment relapse due to
condylar resorption (Fig. 3), were
within the clinically acceptable range of
2 mm and 4° reported in the litera­
ture.4,31 The largest mandibular treat­
ment relapse was observed by a
superior translation of the proximal
segments and the posterior rotation of
the proximal and distal mandibular
segments, indicating condylar resorp­
tion. In severe cases, this may cause an
increased overjet and anterior open
bite. The largest maxillary treatment
relapse was observed in a flaring of the
maxillary segments. This may be
caused by fixation insufficiency and/or
maxillary bone remodelling at the os­
teotomy sites. A posterior rotation of
the chin in genioplasty was observed.
Again, this can be speculated to be
caused by fixation insufficiency and/or
bone remodelling. More data are re­
quired for more definite conclusions.
Semi-automated approaches using
VBR have previously been proposed
for the assessment of the postoperative
outcome and follow-up of orthognathic
surgery.20,21 Shaheen et al.20 proposed
a semi-automated approach using VBR
with excellent repeatability for the
evaluation of the surgical outcome and
short-term follow-up (6 months) ex­
clusively for one-piece Le Fort I os­
teotomy. Their protocol requires the
identification of three landmarks for
the maxillary segment to allow the
calculation of translational and rota­
tional movements.20 Recently, the pro­
tocol was expanded by da Costa Senior
et al.21 to include assessment of the
segmented Le Fort I osteotomy, and
the repeatability remained high. The
reliability results of the VSA proposed
in the present study are similar or better
than the findings in these related stu­
dies,20,21 where exclusively maxillary
osteotomies were assessed and vali­
dated on CBCT scans obtained at the
6-month follow-up, where skeletal re­
modelling has only initiated.32 Re­
modelling is present at osteotomy sites,
and in the case of mandibular ramus
osteotomy, is also due to mechanical
stresses and changed muscular activity
following orthognathic surgery.32,33
Hence, the validity of these short-term
stability assessment protocols may be
limited.20,21 The bone remodelling
processes and the continuous post-sur­
gical orthodontic treatment influences
the mutual image information of long-
term postoperative CBCT scans used
for registration of the individual bone
segments, and thus affects the perfor­
mance of the VSA. Hence, long-term
1194 Holte et al.
Fig. 3. Virtual surgical analysis of the case in the study sample with the largest treatment relapse: preoperative, short-term, and long-
term postoperative CBCT scans, and the postoperative stability illustrated by the distance map and landmark displacement. Magenta
points: short-term postoperative landmark placement; orange points: long-term postoperative landmark placement. Note how the
condyles have resorbed and been displaced antero-superiorly between the short- and long-term postoperative follow-ups, resulting in a
larger posterior rotation of the entire maxillomandibular complex.
(≥2 years) postoperative 3D assessment
using VBR is more challenging than
immediate (≤2 weeks)1 or short-term
(≤6 months) assessments.20,21
Postoperative analysis of the surgical
outcome and treatment stability has
proven valuable in refining surgical
planning and execution.34 For example,
Gunson and Arnett34 discussed how
postoperative analysis helped them to
discover new surgical techniques in
order to overcome previously un­
observed inaccuracies in their surgeries.
In the systematic review and meta-ana­
lysis by Gaitan-Romero et al.4, it was
concluded that further high-quality stu­
dies utilizing standardized 3D meth­
odologies are required. The present
proposed semi-automated VSA facil­
itates 3D stability assessment of all
moving bone segments involved in seg­
mental bimaxillary surgical interven­
tions including genioplasty. This enables
a complete 3D assessment of skeletal
stability and treatment relapse in large
cohorts and facilitates the evaluation
and comparison of orthognathic sur­
gical and fixation techniques, type of
dentofacial deformity, and amount of
surgical movement. For example, com­
parison of the surgical outcome and
stability when using patient-specific im­
plants versus standard fixation, skeletal
stability in class II and III subjects, or
large and small movements. Although
the proposed VSA was proven to be
robust, it should be noted that the size
of the VOI and presence of fixation and
artefacts in the VOI in the postoperative
CBCT are variables that affect VBR.
Previous studies have shown the ro­
bustness of VBR-based approaches ir­
respective of the type of computed
tomography (CT) or CBCT device and
image acquisition settings.14,20 The
CBCT scans in this study were acquired
using a Planmeca Viso G7 scanner
(Planmeca Oy, Helsinki, Finland).
Further evaluation of the VSA with
different CT and CBCT devices and
image acquisition settings is en­
couraged. It is important that the pre-
and postoperative CBCT scans are ac­
quired in correct occlusion with the
condyles seated in centric relation. If
these conditions are not met, the accu­
racy of the VSA will be compromised.
The VSA assesses treatment relapse as
a positional change by registering the
preoperative bone segments from the
VSP. Hence, skeletal remodelling will
solely be visible and recorded by the
positional change and not morpholo­
gically.
It should be noted that this valida­
tion study addressed the reliability of
the VSA in line with similar validation
studies.1,13,14,19–21 The accuracy of the
approach is inherently difficult to infer
due to the lack of ground truth data.
Recently, Han et al.35 addressed the
question “What do we know beyond
reliability in voxel-based registration?”
by attempting to validate the accuracy
of regional VBR for the analysis of
orthognathic surgery. The study
showed excellent accuracy in terms of
rotational measurements when using
the maxilla, distal mandible, and the
bilateral proximal mandibular seg­
ments as VOI for regional VBR.35
However, the ground truth is arguable.
In conclusion, the proposed VSA
expansion was shown to have excellent
reliability for semi-automated 3D as­
sessment of the postoperative stability
of bimaxillary surgery, including seg­
mental Le Fort I osteotomies, BSSO,
and genioplasty. The 3D stability
measurements of all bone segments are
performed using VBR, and the user is
provided with the option to use no ce­
phalometric landmarks (landmark-free)
or a preferred set of landmarks,
without the need for landmark re-
identification. The semi-automated
VSA makes a complete 3D assessment
of long-term skeletal stability in large
cohorts feasible and facilitates the eva­
luation and comparison of surgical
techniques.
The development of robust auto­
mated VSA is important due to the
valuable information it can provide the
surgeon in clinical practice to optimize
the outcomes of orthognathic surgery
via the time efficient assessment of both
surgical accuracy and postoperative
stability. Additionally, the findings of
processing vast amounts of data may
provide a better understanding of the
many variables affecting the outcomes
of orthognathic surgery. Optimally, in
the near future, VSA will become an
integrated part of the planning software
for easy and efficient built-in assess­
ment of the surgical outcome and sta­
bility.
Acknowledgements. The authors thank
Professor Gabriele Berg-Beckhoff,
Department of Public Health, Faculty
of Health Sciences, University of
Southern Denmark, for statistical
advice.
Funding
None.

Competing interests
None.
Ethical approval
Permission was granted by the
Institutional Ethics Committee,
University Hospital of Southern
Denmark, Esbjerg (21/33871). As the
study comprised retrospective material,
none of the patients were exposed to
any extra radiation and no extra ex­
amination was performed to acquire
additional information.
Patient consent
Not required.
Appendix A. Supporting
information
Supplementary data associated with
this article can be found in the online
version at doi:10.1016/j.postharvbio.
2022.111908.
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Correspondence to:
Else Marie Pinholt
Department of Regional Health Research
Faculty of Health Sciences
University of Southern Denmark
Finsensgade 35
6700 Esbjerg
Denmark.
E-mail: empinholt@health.sdu.dk