J Stomatol Oral Maxillofac Surg 123 (2022) 276−282

Available online at

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Review

Artificial intelligence for oral and maxillo-facial surgery: A narrative

review
Simon Rasteaua,*, Didier Ernenweinb, Charles Savoldellic, Pierre Bouletreaua
a
Maxillo-Facial Surgery, Facial Plastic Surgery, Stomatology and Oral Surgery, Hospices Civils de Lyon, Lyon-Sud Hospital − Claude-Bernard Lyon 1 University, 165
Chemin du Grand-Revoyet, Pierre-Be
nite 69310, France
b
Department of Pediatric Oral & Maxillofacial & Plastic Surgery, Children's Hospital Robert-Debre
, Paris-Diderot University, Paris, France
c
^te d'Azur University, Nice University Hospital, 31 Avenue de Valombrose, Nice 06100, France
University Institute of the Face and Neck, Co

A R T I C L E I N F O A B S T R A C T

Article History: Artificial Intelligence (AI) is a set of technologies that simulate human cognition in order to address a specific
Received 23 January 2022 problem. The improvement in computing speed, the exponential production and the routine collection of
Accepted 23 January 2022 data have led to the rapid development of AI in the health sector.
Available online 25 January 2022
In this review, we propose to provide surgeons with the essential technical elements to help them under-
stand the possibilities offered by AI and to review the current applications of AI for oral and maxillofacial sur-
Keywords:
gery (OMFS). The review of the literature reveals a real research boom of AI in all fields in OMFS. The
Artificial intelligence
algorithms used are related to machine learning, with a strong representation of the convolutional neural
Machine learning
Deep learning
networks specific to deep learning. The complex architecture of these networks gives them the capacity to
Artificial neural network extract and process the elementary characteristics of an image, and they are therefore particularly used for
Computer aided diagnosis diagnostic purposes on medical imagery or facial photography. We identified representative articles dealing
Oral and maxillofacial surgery with AI algorithms providing assistance in diagnosis, therapeutic decision, preoperative planning, or predic-
tion and evaluation of the outcomes.
Thanks to their learning, classification, prediction and detection capabilities, AI algorithms complement
human skills while limiting their imperfections. However, these algorithms should be subject to rigorous
clinical evaluation, and ethical reflection on data protection should be systematically conducted.
© 2022 Elsevier Masson SAS. All rights reserved.

1. Introduction overuse of “decision shortcuts” enabled by the heuristic approach

The practice of surgery requires the surgeon to make rapid and
complex decisions, while mastering the sometimes uncertain conse-
quences for the health of patients [1]. Medical education, training,
critical and rational thinking, as well as a logical sense facilitate an
algorithmic mode of reasoning. Each clinical and paraclinical element
is analysed and taken into account, making it possible to deal with all
situations, however unexpected and infrequent they may be [2].
However, a large amount of work does not allow the systematic
deployment of this approach, as it is time-consuming and imposes a
significant cognitive load. In contrast, a heuristic mode of reasoning
does not involve all of the rational processes and available informa-
tion, allowing routine problems to be resolved quickly. This decision
process is strongly impacted by the surgeon's experience, emotional
state, fatigue, context or personality traits [2]. The unconscious
Abbreviations: OMFS, Oral and MaxilloFacial Surgery; AI, Artificial Intelligence; PR,
Panoramic Radiograph; CBCT, Cone Beam Computed Tomography; CNN, Convolutional
Neural Network; DFD, DentoFacial Deformity; CT, Computed Tomography
* Corresponding author.
E-mail address: simon.rasteau@chu-lyon.fr (S. Rasteau).
leads to the development of cognitive biases, i.e. a form of thinking
that systematically and predictably leads to errors of judgement in
certain situations [3]. The presence of cognitive bias in medical think-
ing implies a certain amount of variability, imprecision and even
error at all stages of diagnosis, therapeutic decision and follow-up.
Due to the improvement in computing power, the exponential
production of health data, and the creation of large exploitable data
sets, artificial intelligence (AI) is developing rapidly in the health sec-
tor [4] and could represent a real support to medical reasoning, limit-
ing cognitive biases and thus medical errors. The techniques provided
by AI have the potential to improve the surgeon's practice at all
stages of patient management: screening, diagnosis, therapeutic deci-
sion, surgical procedure, follow-up, etc. More and more algorithms
are now surpassing the capabilities of human experts for some very
specific tasks: detecting breast cancer on a mammogram [5].
However, maxillofacial surgeons seem not to have fully harnessed
the potential of AI yet. Thus, we propose through this narrative
review to address three objectives: (1) to provide the essential tech-
nical elements to maxillofacial surgeons to enable them to apprehend
the possibilities offered by AI, (2) to draw up an overview of the most

https://doi.org/10.1016/j.jormas.2022.01.010
2468-7855/© 2022 Elsevier Masson SAS. All rights reserved.
S. Rasteau, D. Ernenwein, C. Savoldelli et al. Journal of Stomatology oral and Maxillofacial Surgery 123 (2022) 276−282

common applications of AI for OMFS, (3) to assess the future pros-
pects and the difficulties of deployment in daily clinical practice.
2. Artificial intelligence and machine learning
The term Artificial Intelligence brings together a heterogeneous
group of technologies with the capacity to accomplish a task that is
reserved for the human race: learning, perception, reasoning, recog-
nition. . . AI algorithms used are “weak”: they only can answer to the
very specific task for which they were designed, without self-con-
sciousness. The fields of application are vast, with systems for com-
puter vision, automatic learning, automatic language processing and
robotics [6,7].
Machine learning is a discipline of AI that aims to design computer
models capable of performing a task without having been explicitly
programmed to do so [8]. The algorithm is first trained to identify
patterns in a training dataset, which is generally broad, so that it can
later recognise a similar pattern in new data.
Pattern learning can be supervised: the training data is labelled by
human experts prior to training and a feature extractor is specifically
designed for pattern identification (Fig. 1). Once validated, the model
is then able to categorise any new and unlabelled data thanks to its
learning. This is known as generalisation capacity. This type of model
allows classification, detection (of images, texts, sounds, etc.), and
prediction tasks (regression models) to be performed [9].
Conversely, unsupervised learning is performed on unannotated
data, and allows the constitution of homogeneous groups of data
based on similarities in their characteristics (clustering). However, it
remains up to the human expert to provide a semantic explanation
for the groups formed [9]. These algorithms are used to explore and
understand the available data. This type of learning is regularly
deployed in healthcare, due to the complexity of the data and the
high heterogeneity of the patients.
Deep learning is a branch of machine learning, particularly used
for processing complex data (images, videos, sounds) and in natural
language processing [10]. The algorithms used are deep artificial neu-
ral networks, where each layer of neurons breaks down the input
information and extracts features in order to provide an output
result. Neural networks are previously trained on large volumes of
data, in order to optimise the internal parameters and to obtain the
highest correspondence between the input and output layers of the
neural network [11].
In computer vision, the most frequently used neural networks are
called “convolutional neural networks” (CNN). The functioning of this
type of network is based on the physiology of the visual cortex: The
first layers of the network allow the extraction of simple characteris-
tics and the last layers of increasingly sophisticated characteristics,
allowing the detection or classification of an object [11]. The feature
extraction is thus automated and does not require the intervention of
an expert (Fig. 1). Convolutional networks, with their ability to clas-
sify and detect objects, are of great benefit to specialties where image
interpretation is essential, such as radiology, anatomical pathology,
dermatology or ophthalmology.
3. Clinical applications of AI in OMFS
The review of the literature reveals a real research boom in the
area of AI in OMFS (Fig. 2). The algorithms used are related to
machine learning, with a strong representation of the convolu-
tional neural networks specific to deep learning. The algorithms
are employed for diagnostic support, prediction or evaluation of
outcomes, treatment decision support, or preoperative planning.

Fig. 1. How machine learning and deep learning techniques work. In supervised machine learning, the algorithm is trained with a set of labelled data. A specially designed feature
extractor identifies the features associated with the labels to enable training. When a new dataset is provided, the trained algorithm is able to identify these features in order to pro-
duce a result (classification, regression, detection. . .). In deep learning, the deep neural network is trained on an often very large database. The features extractor is not manually
coded and results from the training of the first layers of the network. The internal parameters are adjusted during training by back-propagation of the error within the hidden layers
until a good performing model is obtained. The internal parameters are then locked, and the network can, for example, classify a new image by hierarchical feature recognition, from
the simplest (edge, contour) to the most complex (eye, nose, then face).

277
S. Rasteau, D. Ernenwein, C. Savoldelli et al.
Fig. 2. Number of articles published on Medline annually on the topic of AI in OMFS.
All fields of the specialty present applications of machine learning
techniques, with a majority of articles dealing with orthognathic
surgery, oral cancerology, or oral surgery. We choose to discuss
only these three fields of application, as they are very representa-
tive of AI potential.
3.1. Orthognathic surgery
For patients with dentofacial deformity (DFD), the entire ortho-
dontic-surgical management process benefits from the implementa-
tion of these new technologies, from initial diagnosis to
postoperative follow-up [12].
The majority of articles deal with tools for automatic annotation of
teleradiographs and assistance with cephalometric diagnosis [13].
The automation of this task, which has been shown to be time-con-
suming and to have high inter-operator variability makes it possible
to reallocate medical time, increase the reproducibility of measure-
ments and the comparability of results. Algorithms are now consid-
ered to be at least as efficient as experts [14], and many commercial
solutions are emerging. Several studies have proposed 3-D imaging
analysis tools to optimise the description of the characteristics of cer-
tain complex DFD. The use of machine learning allows the rapid and
reproducible identification and interpretation of the large number
of bone and skin landmarks required for a complete 3D analysis,
and outperforms other computational techniques previously
employed [15].
The irreversible choice of surgery for patients with DFD requires
experience on the part of the orthodontist and surgeon. Training
algorithms on cephalometric values, unannotated imaging studies or
photographs now allows the production of treatment decision sup-
port tools that predict the need for surgery during orthodontic treat-
ment [16] [17]. This type of algorithm helps the practitioner to
confirm or reconsider his decision in order to limit orthodontic cam-
ouflage with sometimes unfavourable aesthetic and functional results
or abusive surgical interventions with high cost and invasiveness.
In order to meet the high demand of patients who are concerned
about the post-operative modification of their appearance, most
planning software now offers simulations of the profile change.
Approximation models and bone-skin displacement ratios used by
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Journal of Stomatology oral and Maxillofacial Surgery 123 (2022) 276−282
these software have however shown their limitations in soft tissue
simulation [18]. On the contrary, AI-assisted analysis of 3D images of
operated patients provides realistic preoperative simulations based
on the results of previous treatment, facilitating surgical planning
and communication with patients [19].
With all these tools at disposal, it will be possible in the near
future to envisage a fully AI-assisted digital workflow able to diag-
nose DFD on the basis of automatic 3D cephalometric, to propose a
highly personalised treatment plan, to perform a realistic surgical
simulation and to evaluate the surgical outcome [12,18]. Such a set of
algorithms will require a large database of operated patients to be
made available to the scientific community for training purposes.
3.2. Cancers of the oral cavity
Carcinomas of the oral cavity are the most common cancers of the
upper aerodigestive tract, with an increasing incidence rate. While
early management usually results in limited surgical sequelae, delay
in diagnosis leads to a reduced survival rate and a sometimes major
functional and cosmetic impact [20]. Early detection of pre-malignant
lesions can prevent their transformation, but remains difficult for
non-specialists. Some machine learning tools allow detection by
autofluorescence measurement [21] or by photography [22]. For
more advanced lesions, Fu et al. proposed a CNN dedicated to the
detection of carcinomas of the oral cavity on photographs, thanks to
training on 6176 images, and obtained performances similar to those
of experts [23]. Note the original work of van de Goor et al. who
trained a neural network to detect carcinomas of the upper aerodi-
gestive tract using data from an "electronic nose", capable of analy-
sing certain volatile compounds in the breath [24]. Screening in
primary care and early management of these lesions will thus be
facilitated when these tools are released into clinical practice.
Other algorithms allow the detection of metastatic lymph nodes
thanks to training on digital parameters from the imaging [25]
revealing texture, grey levels, the relationship between voxels. . . This
technique is known as radiomic analysis or computational imaging.
Machine learning algorithms can correlate these high-dimensional
parameters with diagnostic, clinical and prognostic factors, thus
S. Rasteau, D. Ernenwein, C. Savoldelli et al.
constituting true radiological biomarkers revealing the phenotype
and microenvironment of tumour lesions [26].
Another challenge in the management of cancer patients for the
practitioner is to be able to predict the evolution of the pathology of a
particular subject, according to all the available clinical and paraclini-
cal data. A good risk stratification allows the selection of complemen-
tary investigations to be carried out, the planning of adequate
therapies and the implementation of adapted surveillance [27]. This
assessment is generally made possible by the use of scores whose
clinical, paraclinical or genomic items are validated in statistical
cohort studies. However, it seems to be more difficult to apply at the
level of an individual, due to the large amount of patient and
tumour-related data that is not fully controlled [28]. Thus, several
algorithms have been developed to predict survival [29], risk of
recurrence [30], or risk of postoperative complications [31]. The
training of these algorithms is mainly based on clinico-biological data
from the medical record, underlining the interest of keeping
exploitable prospective registers, and the development of text mining
tools allowing the automatic and structured extraction of data from
the electronic medical record [32]. Of note is the work of Pan et al.
who trained a model on 12 texture parameters from CT images of
tongue carcinoma, and showed results equivalent to experts in terms
of survival prediction [29]. This type of training of predictive models
on radiomic data would make it possible to overcome the difficulty of
compiling and structuring textual and numerical data from the medi-
cal records.
3.3. Oral surgery
Oral surgery is characterised by its extensive use of convolutional
neural networks, which allow the detection and classification of fea-
tures on panoramic radiographs (PR) [33,34] and cone-beam images
(CBCT) [35]. Among these features, radiolucent bone lesions of the man-
dible and maxilla are the most studied [33−41]. These cystic or tumor-
ous lesions, often of odontogenic origin, represent a certain diagnostic
and therapeutic challenge. Their radiographic features are often poly-
morphic, with no pathognomonic sign of a particular diagnosis, and a
clinical history that is generally similar. While some lesions require lim-
ited surgical management of enucleation and curettage, others such as
ameloblastomas may require a more aggressive approach to limit the
risk of tissue destruction, malignant transformation and recurrence
[42]. Depending on their architecture, the algorithms used allow the
automation of part or all of the process of detection, segmentation, fea-
ture extraction and classification of lesions, on PR [33,34] or on CBCT
[35].Two algorithms trained on databases of 500 [33] and 1602 [34]
panoramic images showed similar performance to that of the experts,
and are likely to find a place in non-specialist dental practice screening.
Improving the performance of the classification would probably allow
these models to be used as diagnostic tools and thus to assist specialists
in their treatment decisions.
The extraction of impacted third molars is one of the most com-
mon procedures performed by maxillofacial surgeons, oral surgeons
and dentists. Algorithms have been proposed to optimise the various
stages of management. The decision on the surgical indication for
tooth extraction, which can be controversial in some cases, can be
facilitated by the support of a predictive model of the eruption poten-
tial of the third molars via the automatic measurement of their angu-
lation on PR [43]. While complications, especially neurological ones,
remain frequent, some tools allow to guide the procedure by predict-
ing the surgical difficulty [44] or by detecting a contact with the infe-
rior alveolar canal on the PR [45]. Finally, training an artificial neural
network on 15 clinical parameters provides a predictive score for
postoperative oedema [46].
In implantology, AI has been used so far to recognize implant type
on PR, to predict osteointegration success or implants survival by using
different input data and to improve the design of dental implants by
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Journal of Stomatology oral and Maxillofacial Surgery 123 (2022) 276−282
optimizing the implant design porosity, length, and diameter thus mini-
mizing the stress at the implant-bone interface [47].
The multiplication of automatic detection tools on PR will soon
lead to the availability of complete commercial software for the auto-
mated analysis of this imaging examination. The interpretation of PR
is thus often opaque for the majority of physicians and is only rarely
performed by a radiologist. It would thus be possible to couple these
detection tools with classification or text generation algorithms, in
order to allow the automatic drafting of a radiology report [48].
4. Challenges and development opportunities
The implementation in daily practice of new technologies brought
by AI needs to respond to certain technical, societal and ethical limi-
tations. These limitations may be on the scale of the data, the algo-
rithms, or the application in clinical practice.
Machine learning algorithms require considerable volumes of
data in order to carry out their training and to offer satisfactory per-
formance. However, health data are considered as sensitive personal
data, the protection of which must be ensured at all stages of the
design, deployment and use of the algorithms, according to the prin-
ciple of "privacy by design" [49]. Clear and fair information must be
provided to the subjects whose data is used.
Another major limitation in health is the difficulty of obtaining
datasets of satisfactory volume, particularly for training convolu-
tional networks that are particularly data-intensive [50]. The number
of data needed depends on several factors, such as the type of train-
ing data, the type of algorithm, the number of training parameters, or
the quality of the data [50]. There are several ways to overcome the
problem of small datasets. Certain data augmentation techniques,
particularly in the context of image processing by geometric defor-
mation, make it possible to partially address this problem [51]. More-
over, image recognition algorithms are often trained beforehand on
very large natural image databases, before benefiting from specific
training on a smaller medical image dataset (transfer learning) [51].
Radiomics allows the production of a considerable amount of struc-
tured data used for the generation of diagnostic and predictive mod-
els [52]. Text mining technologies allow the automatic extraction of
unstructured data from the electronic medical record [53]. Finally, it
is now possible to artificially produce training images using genera-
tive adversarial networks from deep learning [54].
The great heterogeneity of health data disseminated within the
medical record therefore implies a major effort to collect, structure
and standardise it in order to fulfil the need for data interoperability
at the technical, semantic and organisational levels [55]. These for-
matted data must therefore be stored in multiparametric, participa-
tory, multicentre databases that are freely accessible to authorised
researchers. The data warehouses developed by several centres thus
participate in the constitution of a health big data, the sum of all real-
life experiences on which the algorithms can be trained [55].
The labelling of the data required for supervised training is gener-
ally carried out by a physician who has access to the entire medical
context studied. This task is extremely time-consuming, takes away
from the time devoted to care, and can lead to labelling errors and
sometimes significant intra-observer variability. The multiplication
of practitioners assigned to this task can lead to a certain inter-
observer variability in labelling and therefore to a biased dataset [56].
Once the dataset has been constituted, it is also up to the physi-
cians to ensure that it is representative of the medical problem or the
population studied. Indeed, any bias introduced within the training
data will be learned and reproduced by the model, leading to approx-
imate or erroneous results. It is therefore strictly necessary to vali-
date the generalisation capacity of the algorithms on new data in the
general population, preferably provided by another team and another
centre, in order to identify and limit these intrinsic biases [56].
S. Rasteau, D. Ernenwein, C. Savoldelli et al. Journal of Stomatology oral and Maxillofacial Surgery 123 (2022) 276−282

Table 1
Glossary of key technical terms.
Artificial intelligence (AI)
Machine learning (ML)
Supervised machine learning
Unsupervised machine learning
Artificial Neural Network (ANN)
Deep learning (DL)
Convolutional neural network (CNN)
Computer vision
Natural Language Processing (NLP)
Big data
Radiomics
A set of theories and techniques used to
design machines capable of simulating
intelligence.
Artificial intelligence technologies that
allow computers to learn to perform a
task (classification, clustering, regres-
sion) without having been explicitly
programmed to do so.
The algorithm is trained on a labelled
dataset to enable it to predict an out-
put value based on new input data.
Performs classification and regression
tasks.
The algorithm identifies patterns within
an unlabelled dataset to form groups
with similar characteristics. Performs
clustering, dimensionality reduction
and anomaly detection tasks.
A machine learning technique for solving
learning problems by imitating the
functions of a biological neural
network.
A subset of machine learning based on
deep neural networks with many
intermediate layers that can identify
patterns in very large data sets.
A type of artificial neural network,
mainly used in computer vision, whose
connection pattern between neurons is
inspired by the visual cortex of ani-
mals. Allows the automatic extraction
of features of different complexity,
from the simplest to the most sophisti-
cated, to allow detection or classifica-
tion tasks.
A branch of artificial intelligence whose
main purpose is to enable a machine to
analyse, process and understand an
image.
Artificial intelligence technology that
enables computers to read, decipher,
understand and make sense of human
language.
Complex data sets, characterised by their
great variety, rapid production and
large volume, which do not allow for
conventional statistical analysis.
Study of quantitative parameters
extracted from radiological images
using mathematical descriptors corre-
lated with biological reality, allowing
for example the determination of the
histological nature of tissues, or the
prediction of diseases outcomes.
harm of an inaccurate model and the potential for intentional harm-
ful use (principle of non-maleficence). Decisions made by AI systems
should not conflict with the freedom of recipients to act on their
own, nor their freedom to decide according to their values and beliefs
(principle of autonomy). Finally, AI systems should contribute to
reduce societal inequalities in health, which are still very present
throughout the world. To this end, these systems will have to be
accessible to as many people as possible, so as not to exacerbate
existing disparities (principle of justice).
Finally, it will also be necessary to respond to the fears of certain
practitioners regarding the growing role of AI in health. The complete
replacement of the practitioner by a strong AI seems at the moment
to be quite unrealistic [59]. The tools currently available only allow
the performance of very specific and limited tasks, and in no way
meet the expected skills of empathy, listening and contextualisation.
It would seem that we are more likely to see the development of AI-
augmented medicine, where the automation of certain repetitive or
time-consuming tasks would free up the time needed by practi-
tioners to carry out complex tasks [60]. However, it will be necessary
to maintain sufficient hindsight and critical thinking with regard to
these technologies, particularly in the context of diagnostic or thera-
peutic decision support tools, in order to avoid any automation bias
(human tendency to favour machine-generated decisions, while
ignoring contradictory data) Table 1.
5. Conclusion
Decision-making in surgical practice is a complex process, which
may call upon the values and emotions of the practitioner, and there-
fore lead to certain cognitive biases that are potentially deleterious to
patient care. Although they have only recently appeared in maxillofa-
cial surgery, the tools provided by Artificial Intelligence to assist in
diagnosis, therapeutic decision, preoperative planning or prediction
of the outcome of surgery can reinforce the practitioner in his daily
practice. Almost all areas of the specialty benefit from these new
technologies, some of which are already performing better than
experts for some specific tasks. However, there are still some chal-
lenges to be overcome, particularly in terms of ethics and data pro-
tection, in order to offer patients efficient, reproducible and
trustworthy augmented medicine. Maxillofacial surgeons will have
to take hold of these new tools and be involved in their design and
deployment within the healthcare system. Training the younger gen-
eration in these new technologies, systematically integrating data
into collaborative databases and decompartmentalising medical and
engineering courses will probably enable this small revolution of AI's
entry into the discipline to be overcome in the years to come.

Declaration of Competing Interest

The authors declare that they have no conflict of interest related

At the algorithmic level, the most important obstacle to the mas-
sive use of AI in health is the poor explicability of the mechanisms
underlying the diagnostic or predictive results of the models. It is in
fact difficult at present to know what weight the different parameters
presented to the algorithms have in the decision, whose increasingly
complex architecture is assimilated to a black box. It seems funda-
mental to answer this problem in order to allow the full acceptance
of AI within health care structures, both by patients and by doctors. A
dialogue will also have to be held on the responsibility of algorithmic
decision-making, particularly in the event of medical error linked to
the use of a machine learning model [57].
From an ethical point of view, it is necessary to ensure that the
deployment of AI is done in compliance with the moral values funda-
mental to the practice of medicine [58]. AI algorithms, because of
their ability to improve patient care, must be studied and imple-
mented (principle of beneficence), while avoiding the unintended
280
to this article.
Funding
This research did not receive any specific grants or funding from
agencies in the public, commercial, or not-for-profit sectors
CRediT authorship contribution statement
Simon Rasteau: Data curation, Writing − original draft, Writing −
review & editing. Didier Ernenwein: Data curation, Writing − origi-
nal draft, Writing − review & editing. Charles Savoldelli: Data cura-
tion, Writing − original draft, Writing − review & editing. Pierre
Bouletreau: Data curation, Writing − original draft, Writing − review
& editing.
S. Rasteau, D. Ernenwein, C. Savoldelli et al.
Acknowledgement
que
The translation of this article was supported by the Bibliothe
scientifique de l’Internat de Lyon and the Hospices Civils de Lyon
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