Virtual planning: an experience-dependent decision-making tool?

In orthognathic surgery, the transition from traditional 2D methods — often time-consuming and imprecise for complex anatomy — to 3D virtual surgical planning (VSP) promises better predictability. However, while the technical benefits of VSP are documented, its actual influence on surgeons' decision-making processes, depending on their level of expertise and case volume, lacked systematic evidence.

This multi-institutional cross-sectional study was designed to address this gap. Its primary objective is to evaluate how the integration of VSP modifies surgical strategies and impacts practitioner confidence. By analysing the responses of 18 surgeons (plastic and maxillofacial) presented with a standardised clinical case, the authors explore the hypothesis of a volume-dependent effect of the technology.

The study seeks to verify whether 3D visualisation can reduce planning disparities between low-volume practitioners (0-5 cases/year) and high-volume practitioners (>20 cases/year). By measuring satisfaction and the revision of initial treatment plans following exposure to software simulations, the objective is to determine whether VSP acts as a decision support tool capable of standardising complex surgical practices.

Study methodology

This study is based on a multi-institutional cross-sectional survey conducted among 18 plastic and maxillofacial surgeons. The sample, with a median experience of 19.5 years (IQR [9.25-25]), was segmented into three categories according to the annual volume of orthognathic procedures: low (0-5 cases), moderate (6-20 cases) and high (>20 cases).

The experimental protocol was carried out according to the following steps:

• Initial assessment: The practitioners analysed a standardised and anonymised clinical vignette, then requested additional data (78% requested a lateral cephalometric radiograph and 67% a CT scan).
• Planning: The surgeons proposed a primary treatment plan prior to any digital assistance.
• VSP simulation: The IPS CaseDesigner software was used to model the initial plan as well as alternative strategies in three dimensions.
• Validation: The participants then formulated their final surgical plan.

The primary endpoint measured the change in practitioners' confidence and satisfaction on a 10-point scale, before and after using the VSP. Statistical analysis was performed in R (version 4.5.1), using Fisher's exact and Chi-square tests for binary variables, and the Mann-Whitney U test for continuous data.

Participant profile and clinical priorities

The study included 18 senior surgeons (median years in practice: 19.5 years, IQR [9.25-25]). The cohort presented a varied distribution of annual caseload: 44% low volume (0-5 cases), 28% moderate volume (6-20 cases) and 28% high volume (>20 cases). During the initial assessment, practitioners prioritised the mandibular midline (89%), the maxillary midline (78%), incisor exposure (72%) and profile analysis (83%). Lateral cephalometric radiography was the most requested examination (78%), ahead of CT scans (67%).

Impact of VSP on confidence and satisfaction

The integration of virtual surgical planning (VSP) generated variations in confidence correlated with the surgeons' activity volume. Although overall satisfaction increased by 1.06 points on average, this increase is not statistically significant across the entire cohort (p=0.23; 95% CI [-0.75; 2.86]).

Modifications of operative strategies

The most notable turning point concerns the revision of the initial treatment plan. Out of the 18 participants, 5 modified their surgical strategy after consulting the VSP simulation. All of these surgeons (100%) belonged to the group performing fewer than 10 cases per year.

• The association between a low activity volume and the modification of the plan induced by VSP is statistically significant (p=0.016).
• High-volume practitioners maintained high baseline confidence, but paradoxically showed a slight decrease in post-VSP satisfaction, suggesting a reassessment of their usual strategies when faced with 3D alternatives.

These data demonstrate that VSP acts as a critical decision support tool, particularly for practitioners less exposed to these complex surgeries, by securing their therapeutic choice.

Clinical analysis: VSP, a skills equaliser

The results of this study demonstrate that virtual surgical planning (VSP) is not merely a technical convenience, but a true decision-making driver. For practitioners performing fewer than 10 cases per year, the impact is major: 100% of treatment plan revisions following simulation were carried out by this group (p=0.016). The increase in confidence, jumping from 5.5 to 8.38/10, suggests that 3D effectively compensates for the lack of clinical repetition by securing the preoperative approach.

Key finding: while high-volume surgeons maintain high initial confidence (9/10), their satisfaction decreases slightly after exposure to VSP (8.8/10). This indicates that 3D visualisation and predictive models prompt even the expert to question their certainties when faced with complex anatomical alternatives. In clinical practice, this means that VSP acts as a safeguard against cognitive biases related to surgical routine.

The weakness of this study lies in its small sample size (n=18), which limits the statistical power of certain results, particularly the overall increase in satisfaction (p=0.23). Nevertheless, the priority given to the analysis of the mandibular midline (89%) and incisor exposure (72%) highlights that surgeons now use VSP to refine aesthetic and functional parameters that 2D (lateral cephalometric radiography requested by 78% of participants) struggles to capture accurately.

Summary of results

This multi-institutional study shows that virtual planning (VSP) alters surgical decisions primarily among surgeons performing fewer than 10 cases per year (p=0.016), boosting their confidence from 5.5 to 8.38/10. For experts (>20 cases/year), while initial confidence is high (9/10), 3D visualisation induces a slight decrease in satisfaction (8.8/10), suggesting a beneficial reassessment of their usual strategies when faced with modelled alternatives.

In practical terms, for the practitioner:

• Secure your low-volume cases: If you treat fewer than 10 orthognathic cases per year, VSP is an essential decision-making tool to stabilise your treatment plan and significantly reduce clinical uncertainty.
• Challenge your expert intuition: Even with proven experience, use 3D simulation to compare your choices against predictive models; the study suggests that VSP enables the detection of anatomical nuances missed by traditional 2D methods.
• Standardise your analysis: Focus your simulations on the midlines (mandibular and maxillary) and incisal exposure, identified in this study as the major decision-making priorities for 72% to 89% of surgeons.

Technical Glossary of the Study

Virtual Surgical Planning (VSP): Process using 3D modelling and preoperative simulation to visualise complex anatomy and test surgical strategies before the procedure.

IPS CaseDesigner: Specific planning software used in this study to simulate the initial and alternative surgical approaches.

Standardised case vignette: De-identified clinical case presented to participants to evaluate their decision-making process in a uniform manner.

Lateral cephalogram: Profile radiographic examination, requested by 78% of the surgeons in the study as an essential adjunct to planning.

Annual case volume: Segmentation variable used to classify surgeons into three groups: low (0-5 cases), moderate (6-20 cases) and high (>20 cases).

Midface/mandibular profile analysis: Aesthetic and structural evaluation of the middle and lower facial thirds, prioritised by 83% of participants during treatment planning.

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