01-Comphensive Assessment
Successful orthognathic treatment planning begins with a comprehensive assessment that transcends the analysis of a single facial feature or jaw measurement. This holistic evaluation is crucial in understanding the intricate relationships between various anatomical components, ensuring that treatment is tailored to the individual’s unique needs.
In our assessment, we meticulously consider the interplay of facial proportions and symmetry, the positioning of the maxilla and mandible, and the dental occlusion and bite. The alignment of upper and lower dental arches, chin position and overall facial profile are also integral to our analysis. Additionally, we evaluate jaw function and, when clinically relevant, the status of the temporomandibular joints. Concerns regarding airway and breathing are addressed when pertinent, alongside the patient’s primary functional and aesthetic desires.
Our clinical examination is complemented by appropriate diagnostic records, which may include standardized facial and intraoral photographs, panoramic and cephalometricographs, and advanced CBCT imaging. This comprehensive approach ensures that we have a complete understanding of each patient's condition, paving the way for effective and personalized orthognathic treatment.
02- Diagnosis Before Treatment
Orthognathic treatment begins with establishing an accurate diagnosis of the underlying skeletal and dental problem. Before deciding which operation may be appropriate, it is important to understand how the upper jaw, lower jaw, teeth, chin and surrounding facial structures relate to one another.
Facial appearance alone is not sufficient to determine a surgical plan. Similar profiles can result from very different skeletal relationships. For example, a retrusive facial profile may be related primarily to the position of the lower jaw, the upper jaw, the chin, or a combination of these structures. Vertical facial proportions and asymmetry can further influence how these relationships appear clinically.
For this reason, diagnosis combines the clinical examination with evaluation of the dental occlusion and appropriate imaging. Facial proportions and symmetry are assessed together with the relationship between the upper and lower dental arches. Depending on the individual case, panoramic and cephalometric radiographs, CBCT imaging, intraoral scans or digital dental models may provide additional information about the underlying anatomy.
An important part of this process is distinguishing the skeletal discrepancy from dental compensation. When a jaw discrepancy has been present for many years, the teeth may gradually incline or reposition within the bone in a way that partially compensates for the skeletal relationship. The bite seen during the initial examination therefore does not always represent the full extent of the underlying jaw discrepancy.
This distinction becomes particularly important when orthodontic treatment and orthognathic surgery are being planned together. In many cases, orthodontic preparation is designed to position the teeth appropriately within their respective jaws before the skeletal correction is performed. The orthodontic and surgical objectives therefore need to be considered as parts of the same treatment plan.
The diagnostic evaluation also helps determine where the principal skeletal discrepancy is located. It may predominantly involve the maxilla, the mandible, both jaws, the chin, vertical facial proportions, facial asymmetry, or a combination of these factors. Temporomandibular joint findings and airway-related concerns may also be considered when they are clinically relevant.
Identifying a skeletal discrepancy does not automatically mean that surgery is necessary. The significance of the findings, the patient’s functional concerns, orthodontic possibilities, facial relationships and individual treatment objectives all need to be considered before recommending a particular approach.
The aim is therefore not to select an operation first and adapt the patient to that procedure. The sequence should be the opposite: first define the anatomical, dental and functional problem, and then determine which treatment strategy—if any—is appropriate.
Once these relationships have been clearly established, the diagnosis becomes the foundation for the next stages of treatment, including orthodontic coordination and individualized three-dimensional surgical planning.
03 — Digital Surgical Planning
Orthognathic surgery involves three-dimensional changes in the position and relationship of the facial skeleton. Once the diagnosis has been established, digital surgical planning can be used to translate these findings into a structured surgical strategy.
The planning process begins by creating an accurate three-dimensional representation of the craniofacial skeleton. Depending on the case, CBCT data can be combined with digital dental models or intraoral scans to evaluate the maxilla, mandible, dentition and surrounding skeletal structures within the same virtual environment.
This allows the proposed movements of the jaws to be examined in three dimensions rather than relying exclusively on conventional two-dimensional measurements. The maxilla and mandible can be virtually repositioned while changes in the dental occlusion, facial symmetry, skeletal relationships and overall facial proportions are assessed.
Planning is not limited to determining how many millimetres a jaw should move forward or backward. The direction and geometry of movement are equally important. Advancement, setback, vertical repositioning, rotation and correction of asymmetry may need to be considered individually or in combination.
The occlusion remains a central component of this process. Digital dental models allow the relationship between the upper and lower teeth to be evaluated together with the proposed skeletal movements. This is particularly important when surgical planning is coordinated with preoperative orthodontic treatment.
Three-dimensional planning can also help identify anatomical considerations that may influence the surgical approach. Differences between the right and left sides, variations in bone anatomy and the relationship of planned osteotomies to surrounding structures can be evaluated before entering the operating room.
When genioplasty is considered together with jaw surgery, the chin should also be assessed in relation to the final anticipated position of the jaws. This helps avoid treating the chin as an isolated structure without considering the skeletal changes produced by the primary orthognathic procedure.
The objective of virtual planning is not to create an artificial or standardized facial result. It is to develop an individualized surgical plan based on the patient’s anatomy, diagnosis, occlusion and treatment objectives.
Once the virtual plan has been established, the planned skeletal and dental relationships can be transferred to the surgical procedure using appropriate techniques such as digitally designed surgical splints or other patient-specific transfer methods when indicated.
Digital technology therefore functions as a planning and communication tool within a broader clinical process. It does not replace clinical examination, diagnosis or surgical judgment. Instead, it allows these elements to be integrated into a three-dimensional representation of the proposed treatment before surgery.
04- Individualized Surgical Strategy
No two orthognathic surgery plans are exactly the same. Even when patients present with apparently similar facial profiles or bite problems, the underlying skeletal anatomy, dental relationships, facial proportions and treatment objectives may be different. For this reason, the surgical strategy should be developed individually rather than applying a standardized set of jaw movements.
Following comprehensive assessment, diagnosis and three-dimensional planning, the proposed skeletal movements are considered as a coordinated whole. The position of the maxilla, mandible and chin is evaluated in relation to the dental occlusion, facial midline, vertical facial proportions, profile and symmetry.
Depending on the diagnosis, treatment may involve movement of a single jaw or coordinated repositioning of both jaws. Maxillary surgery may include advancement, vertical repositioning or rotational changes. Mandibular surgery may similarly involve advancement, setback or correction of asymmetry. In selected cases, genioplasty can be incorporated into the treatment plan when additional modification of chin position is appropriate.
The magnitude of movement is only one component of surgical planning. The direction and rotation of the skeletal segments can have an important influence on the final relationship between the jaws, teeth and facial skeleton. Pitch, roll and yaw may therefore be considered alongside conventional linear movements when developing a three-dimensional strategy.
Occlusion remains a fundamental reference throughout this process. The planned skeletal correction must be coordinated with the position of the teeth and the objectives of orthodontic treatment. Communication between the surgeon and orthodontist is therefore particularly important in patients undergoing combined orthodontic and surgical treatment.
Facial symmetry is also evaluated in three dimensions. When asymmetry is present, the objective is not simply to move one point toward the facial midline. Differences in the maxilla, mandible, chin, dental arches and surrounding skeletal structures may contribute to the overall appearance and need to be considered together.
Functional factors may also influence the strategy. Depending on the individual case, jaw function, temporomandibular joint findings and airway-related considerations can form part of the overall assessment and treatment decision.
The purpose of an individualized surgical strategy is therefore not to pursue a predetermined facial shape or a universal set of measurements. It is to develop a coherent treatment plan based on the patient’s specific skeletal anatomy, dental relationships, functional requirements and clinically appropriate treatment objectives.
The final surgical strategy represents the integration of the preceding stages: assessment defines the patient’s characteristics, diagnosis identifies the underlying problem, digital planning allows the proposed correction to be evaluated, and individualized surgical planning determines how that correction can be approached.
05- Postoperative Follow-Up
Postoperative follow-up is an essential part of orthognathic treatment. Surgery changes the position of the facial skeleton immediately, but recovery and adaptation continue over the following weeks and months. For this reason, evaluation does not end when the surgical procedure is completed.
During the early postoperative period, follow-up focuses on healing, swelling, pain control, oral hygiene, nutrition and the stability of the dental occlusion. The surgical sites and intraoral incisions are assessed, and the relationship between the upper and lower teeth is monitored as postoperative swelling gradually decreases.
Elastics may be used when indicated to guide the bite during the early stages of healing. Their configuration and duration can be adjusted according to the individual patient’s occlusion and progress. Jaw movement and mouth opening are also monitored as function gradually returns.
Sensory changes are another important aspect of recovery, particularly following lower jaw surgery. Temporary altered sensation or numbness of the lower lip and chin can occur because of the anatomical relationship between the inferior alveolar nerve and the mandible. Changes in sensation are followed over time as nerve recovery progresses.
Facial swelling does not resolve immediately. A substantial proportion of postoperative edema decreases during the first weeks, while more subtle changes can continue for several months. The lips, cheeks, muscles and other soft tissues also gradually adapt to the new position of the underlying facial skeleton. Consequently, the facial appearance observed during the early postoperative period should not be considered the final result.
Jaw function is assessed throughout recovery. Mouth opening, mandibular movements, chewing ability and, when clinically relevant, temporomandibular joint symptoms are evaluated during follow-up. Patients gradually progress through different stages of diet and functional activity according to healing and the specific surgical procedure performed.
The dental occlusion is particularly important during this period. Orthognathic surgery establishes a new skeletal relationship, but postoperative orthodontic treatment may still be required to refine tooth positions and optimize the final bite. Coordination between the surgeon and orthodontist therefore continues after surgery when combined treatment is being performed.
Radiographic or three-dimensional imaging may be obtained when clinically indicated to evaluate skeletal healing, fixation or other specific concerns. Routine follow-up is individualized according to the operation performed and the patient’s recovery.
Later postoperative assessments increasingly focus on skeletal stability, occlusion, facial adaptation, function and any remaining patient concerns. These evaluations help distinguish normal stages of recovery from findings that may require additional assessment.
Postoperative follow-up should therefore be considered a continuation of the original treatment plan rather than a separate stage. Assessment, diagnosis, digital planning, surgery and recovery form a connected clinical pathway, with ongoing evaluation helping guide the patient from the immediate postoperative period toward longer-term functional and skeletal stability.