Abstract
Virtual surgical planning (VSP) and patient-specific implants (PSIs) are increasingly used to translate digital orthognathic plans to surgery with greater precision, particularly in surgery-first orthognathic (SFO) protocols where pre-surgical orthodontics no longer absorbs planning error. We report two SFO cases managed at a single centre using VSP, customized cutting guides, and titanium PSIs. Case 1 was a 19-year-old male with maxillary hypoplasia and mandibular hyperplasia treated by Le Fort I osteotomy, vertical ramus osteotomy, and genioplasty. Case 2 was a 30-year-old female with facial asymmetry from unilateral mandibular hyperplasia treated by Le Fort I osteotomy, bilateral sagittal split osteotomy, and mandibular contouring. Both achieved satisfactory functional, occlusal, and aesthetic outcomes at six months without major complications. Maxillary PSI fixation supported predictable plan transfer in both cases, whereas mandibular management still required case-specific strategies. We discuss this pattern in light of current literature.
Introduction
Orthognathic surgery aims to correct skeletal dentofacial deformities and improve both function and aesthetics. The conventional three-phase pathway places pre-surgical orthodontics before surgery, which prolongs treatment and can temporarily worsen facial appearance during dental decompensation [1–3]. The surgery-first orthognathic (SFO) approach reverses this sequence, beginning with skeletal correction and using post-surgical orthodontics for final dental positioning. Systematic reviews report no significant differences in skeletal stability between SFO and the conventional approach in Class II and Class III cases, with additional benefits of shorter total treatment time and earlier aesthetic improvement [1, 4].
Translating an SFO plan to the operating room demands precision because no pre-surgical orthodontic phase exists to absorb planning inaccuracies. Virtual surgical planning (VSP), customized cutting guides, and patient-specific implants (PSIs) are the principal tools for this purpose. PSIs are titanium plates designed from the patient’s three-dimensional anatomy and the planned final position, allowing waferless or simplified fixation [5–7]. Their published accuracy compares favourably with CAD/CAM splints and conventional mini-plates [6–8].
We report two SFO cases (Table 1) performed with VSP and PSIs at a single centre, representing two distinct indications: severe Class III sagittal discrepancy and facial asymmetry from unilateral mandibular hyperplasia. We place the surgical findings in the context of current literature.
Summary of cases
| Variable | Case 1 | Case 2 |
|---|---|---|
| Age, sex | 19, male | 30, female |
| Diagnosis | Maxillary hypoplasia and mandibular hyperplasia (Class III) | Unilateral (left) mandibular hyperplasia with maxillary asymmetry |
| Growth status confirmation | Age, clinical stability | Serial CT scans, stable clinical findings over time, age |
| Maxillary procedure | Le Fort I: 3 mm advancement, 2 mm anterior down-graft, 4 mm posterior impaction | Le Fort I: 2 mm R down-graft, 8 mmL impaction, 2 mm advancement, 2 mm leftward shift |
| Mandibular procedure | Bilateral VRO (7 mm set-back, 1 mm upward) plus genioplasty (4 mm advancement) | BSSO (follow-the-maxilla) plus left proximal mandibular contouring |
| Maxillary fixation | PSI, waferless | PSI, waferless |
| Mandibular fixation | IMF (no plate) | Miniplates and screws |
| IMF duration | 6 weeks | 2 weeks |
| Follow-up duration | 6 months | 6 months |
| Surgical site infection | None | None |
| Plate exposure/hardware failure | None | None |
| Relapse/revision surgery | None | None |
| Outcome at 6 months | Stable occlusion, post-surgical orthodontics ongoing | Symmetric face, canting corrected, stable occlusion |
Case series
Both patients gave written informed consent for publication of clinical details and images. Per institutional policy at Universitas Indonesia Hospital, formal ethics committee approval is not required for case reports. SFO was performed using VSP, customized cutting guides, and medical-grade titanium PSIs fabricated by selective laser melting. All procedures were performed under general anaesthesia with the patient in the supine position. Postoperative photographs in both cases were taken at two months, and follow-up extended to six months.
Case 1
A 19-year-old male presented with an uncomfortable bite and difficulty chewing attributed to progressive mandibular protrusion. He had no systemic comorbidities or family history of craniofacial anomalies. Extraoral examination showed a skeletal Class III pattern with retruded upper lip, depressed malar region, and acute nasolabial fold. Intraorally, he had bilateral Class III canine and molar relationships, anterior open bite of 1 mm, anterior crossbite with overjet of −7 mm, and bilateral posterior crossbite. Imaging confirmed maxillary hypoplasia in both anteroposterior and vertical dimensions and mandibular hyperplasia in the anteroposterior dimension (Figs 1 and 2).
Preoperative clinical photographs of Case 1: (a–d) facial profile and frontal views demonstrating Class III malocclusion features, and (e–i) intraoral occlusal views.
Preoperative imaging of Case 1: (a–c) three-dimensional CT reconstructions and (d–e) panoramic and lateral cephalometric radiographs.
The VSP-derived plan comprised Le Fort I osteotomy with 3 mm advancement, 2 mm anterior down-graft, and 4 mm posterior impaction, bilateral vertical ramus osteotomy (VRO) with 7 mm set-back and 1 mm upward adjustment, and genioplasty with 4 mm advancement (Fig. 3). The Le Fort I osteotomy was performed through a vestibular incision using piezosurgery, with osteotome assistance at the nasal septum and pterygomaxillary junction. The maxilla was repositioned and fixed using PSIs (Fig. 4a and b). VRO was performed via an intraoral approach with a printed cutting guide (Fig. 4c–e). Genioplasty was fixed with a 4 mm chin plate (Fig. 4f). Alar cinch suture and V–Y closure were applied. The patient was placed in intermaxillary fixation (IMF) for six weeks on a liquid diet.
Virtual surgical planning for Case 1: (a) Le Fort I cutting guide, (b) maxillary patient-specific implant, (c) vertical ramus osteotomy cutting guide.
Case 1 intraoperative views: (a) Le fort I cutting guide on the maxilla, (b) maxillary patient-specific implant in place, (c–d) vertical ramus osteotomy cutting guide fixed on the mandible, (e) schematic illustration of cutting guide positioning, (f) 4 mm chin fixation plate during genioplasty.
At six months, follow-up demonstrated stable skeletal and dental alignment with no surgical site infection, plate exposure, hardware failure, or revision surgery. Post-surgical orthodontics had been initiated for alignment and retraction (Fig. 5).
Postoperative findings in Case 1 at two months: (a–c) clinical facial profile and frontal views, (d) panoramic radiograph, (e) occlusion.
Case 2
A 30-year-old female presented with mandibular asymmetry and mild left temporomandibular joint (TMJ) pain. Prior arthrocentesis had relieved the TMJ symptoms. Examination showed occlusal canting and marked hyperplasia of the left mandibular body, ramus, and condyle, with mandibular deviation to the right on opening and mild tenderness over the left joint. Dental midlines were displaced from the facial midline but coincident with the chin point. She had bilateral Class I canines, left Class I molars, absence of tooth 46, and mild crowding (Fig. 6). Imaging confirmed unilateral mandibular hyperplasia with secondary maxillary asymmetry, while the dentoalveolar components remained within normal limits (Fig. 7).
Preoperative clinical photographs of Case 2: (a–d) facial profile and frontal views demonstrating occlusal canting and left mandibular hyperplasia, and (e–i) intraoral occlusal views.
Preoperative imaging of Case 2: (a) panoramic radiograph, (b) posteroanterior cephalometric radiograph, (c) lateral cephalometric radiograph, and (d–f) three-dimensional CT reconstructions illustrating unilateral mandibular hyperplasia and secondary maxillary asymmetry.
Active mandibular growth was considered to have ceased on the basis of serial computed tomography (CT) scans showing no progression, clinical findings that remained stable over time, and patient age. Combined with resolution of TMJ symptoms after arthrocentesis, this supported a single-stage asymmetry correction without prior condylectomy.
The VSP-derived plan included Le Fort I osteotomy with 2 mm right down-graft, 8 mm left impaction, 2 mm anterior advancement, and 2 mm bodily shift to the left to correct midline deviation (Fig. 8). The maxilla was fixed with PSIs in the same manner as Case 1 (Fig. 9a and b). Bilateral sagittal split osteotomy (BSSO) was then performed to allow the mandible to follow the maxilla while preserving the existing occlusion. The osteotomy was guided by a printed BSSO cutting guide and completed using Lindemann and fissure burs with piezoelectric assistance. The mandible was repositioned to the final wafer and fixed with miniplates and screws (Fig. 9c). Left proximal mandibular contouring was then performed intraoperatively based on clinical judgement, using a Lindemann bur to reshape the bony prominence. Alar cinch suture and V-Y closure were applied. IMF was maintained for two weeks on a liquid diet.
Virtual surgical planning for Case 2: (a) Le Fort I cutting guide, (b) maxillary patient-specific implant, (c) bilateral sagittal split osteotomy cutting guide.
Case 2 intraoperative views: (a) Le Fort I cutting guide on the maxilla, (b) maxillary patient-specific implant in place, (c) final occlusal wafer during bilateral sagittal split osteotomy repositioning.
At six months, follow-up demonstrated symmetric facial form, stable occlusion, and no recurrence of TMJ symptoms. No surgical site infection, plate exposure, hardware failure, or revision surgery occurred (Fig. 10).
Postoperative findings in Case 2 at two months: (a–c) clinical facial profile and frontal views, (d–e) occlusion, (f–h) panoramic, lateral cephalometric, and posteroanterior cephalometric radiographs.
Discussion
Indications and applicability of SFO
SFO was originally proposed for patients with well-aligned to mildly crowded dentition, flat to mild curve of Spee, and minimal transverse discrepancies [3]. The scope has since broadened as VSP allows simulation of the final occlusion through post-surgical dental movements [1]. Our cases sit at two ends of this spectrum. Case 1 fits the broadened SFO indication for Class III malocclusion with severe sagittal discrepancy, where Choi et al. and others have reported the acceleration phenomenon and total treatment time reduction of 6 to 12 months [9]. Case 2 represents a more demanding application: SFO for facial asymmetry from unilateral mandibular hyperplasia, an indication addressed by Choi et al. for non-syndromic developmental asymmetry [9] and by López et al. when combined with condylectomy for active condylar hyperplasia [10]. In our Case 2, growth had ceased and TMJ symptoms had resolved, so condylectomy was not required and SFO proceeded as a single-stage correction.
Translating the digital plan
VSP allows precise simulation of bony movements and is now standard for complex three-dimensional corrections [5, 6]. Its value in SFO is particularly clear because there is no pre-surgical orthodontic phase to mask planning error. Customized cutting guides standardize osteotomy position, while PSIs fix the segment in the planned location and can replace or supplement the conventional intermediate wafer [5]. In both of our cases, the maxillary PSI obviated the need for an intermediate wafer at the Le Fort I level, supporting a true waferless maxillary repositioning. Mandibular repositioning in both cases still relied on the final wafer, supported by cutting guides for the VRO and BSSO osteotomies.
Accuracy and stability of PSI-based fixation
The 2023 systematic review and meta-analysis by Diaconu et al. [7] synthesized 21 three-dimensional studies in 566 patients and reported significantly higher accuracy for PSI compared with CAD/CAM splints or conventional osteosynthesis, with mean differences of 0.85 mm linearly and 2.35° angularly. The randomized trial by Li et al. [6] confirmed this accuracy advantage in bimaxillary cases. For Le Fort I osteotomy, Kotaniemi et al. [11] reported stability with PSI comparable to mini-plates at one year, and the splintless RCT by van der Wel et al. [8] demonstrated comparable one-year skeletal stability with PSI fixation. For BSSO, the recent study by Merta et al. [12] found skeletal stability comparable to mini-plate fixation. We did not perform planned-versus-achieved measurements in our cases, so outcomes are reported descriptively. Both patients achieved the intended occlusal and aesthetic correction without complication or relapse at six months, consistent with the accuracy and stability profile described in the cited literature.
Choice of mandibular procedure
The central surgical observation from this series concerns the mandible. Whereas maxillary PSI fixation was applied identically in both cases, the mandibular approach differed. VRO with intermaxillary fixation was used in Case 1 to permit a large mandibular set-back with low risk of inferior alveolar nerve injury, while BSSO with miniplate fixation in Case 2 allowed three-dimensional repositioning with controlled segment rotation required for asymmetry correction. PSI fixation was not used for the mandibular procedures in either case. Current literature on PSI fixation for VRO is limited because VRO does not produce a stable bony interface for plate engagement, and conventional IMF or short-plate fixation remains standard [13]. PSI fixation for BSSO has been described and supports stable skeletal positioning [12], and is an option worth considering in future asymmetry cases where the proximal segment position is critical. The pattern in our two cases mirrors the wider literature, in which PSI evidence is strongest for the maxilla and remains less developed for the mandible.
Mandibular contouring and translation gaps
Left proximal mandibular contouring in Case 2 was performed by intraoperative judgement rather than VSP-derived planning. Although VSP can simulate contouring, the soft tissue envelope, residual symmetry after osteotomy, and intraoperative palpation often guide the final shaping. This pragmatic combination of digital planning for hard tissue movement and intraoperative judgement for surface contouring reflects current practice but represents a translation gap that future digital workflows may close.
Limitations
This series is limited to two cases at a single centre with six months of follow-up. Planned-versus-achieved measurements were not performed, so accuracy was assessed clinically rather than quantitatively. Longer-term skeletal stability beyond the post-surgical orthodontic phase is not reported. Cost-effectiveness of PSI-based SFO compared with conventional fixation has not been quantified in this study and remains an open question in the broader literature.
Conclusion
Maxillary patient-specific implants supported precise plan transfer in both a Class III sagittal correction and a facial asymmetry case treated with the surgery-first approach. Mandibular management, in contrast, remained individualized: VRO with intermaxillary fixation in the Class III case, and BSSO with miniplate fixation plus freehand contouring in the asymmetry case. This pattern reflects the current literature, where PSI evidence is more developed for the maxilla than for the mandible. Wider adoption would benefit from standardized quantitative outcome reporting, longer follow-up, and clearer indications for PSI fixation in mandibular procedures.
Acknowledgements
The authors thank the patients, and 3D Gens Sdn Bhd (Malaysia) for designing and manufacturing the implants and cutting guides.
Conflicts of interest
The authors received no personal compensation from 3D Gens Sdn Bhd or Gens Tekno Aditif and declare no conflicts of interest.
Funding
Supported by Universitas Indonesia Innovation Funding Scheme P3 (2025) to Prof. Sugeng Supriadi (Decree No. 1225/SK/R/UI/2025).
Ethical approval
Per Universitas Indonesia Hospital policy, ethics committee approval is not required for case reports. Written informed consent for publication was obtained from both patients.
