Pacific Coast Society of Orthodontists Bulletin Fall 2021 - 49

Let's Talk About That
the surgeon is flying their case into the side of
a mountain, and they will gently persuade the
surgeon to get back on course . . . but don't count
on that. Every case report comes with fine print
that basically says, " you are responsible for the
final plan. "
Another opportunity for epic failure occurs
when surgeons inappropriately delegate certain
crucial steps such as obtaining an accurate bite
registration, properly registering and measuring
their rendered 3D CBCT images, or orienting
the segmented CBCT before starting a planning
meeting. It all goes downhill from there if these
steps aren't given a great deal of respect, and
the worst thing about this is that it may take a
few weeks for facial edema to subside before the
unexpected outcome becomes evident, such as a
midline that doesn't match the face or an obvious
occlusal plane cant. These issues place an enormous
burden on the orthodontist who is stuck
with trying to finish the case or the patient who is
faced with another operation. Please don't misunderstand:
we all have surgical takebacks, but we
need to keep them as infrequent as possible.
PT: What do you think is the future of the digital
approach to orthognathic surgery? What advances
are necessary to improve the protocols?
RR: I see future innovations in several areas. For
one, just as with orthognathic surgery, digital
has affected the field of orthodontics. Diagnostic
wax-ups can be done digitally, and custom
appliances can be individualized to very specific
patient situations. The problem is that there isn't
yet a bridge that allows the orthodontist and
surgeon to merge these two technologies into
one seamless treatment plan. Imagine being able
to step our patients through the entire combined
orthodontic and orthognathic surgery process
and to be able to show them their anticipated
treatment result in 3D before even starting the
case. That will happen. We also need improvements
in the automation of CBCT segmentation
and more user-friendly interfaces for surgical
planning. Yes, it can be done right now, but the
process is too time-consuming, at least for us, to
take over the entire 3D virtual surgical-planning
process. Surgical planning on a virtual reality
platform is available even now, and I expect that
interfaces like it will continue to improve.
I also envision a time when there will be no
need for a dental lab in the surgeon's office. No
impressions and no plaster. Some would say we
are already there, but I am not ready to delegate
occlusion setting to the virtual surgical planning
specialists just yet. I like to sense the occlusal
contacts through my hands when we are doing
model surgery. I think that digital will ultimately
replace that sensation with some sort of haptics
or possibly an enhanced visual or audible feedback
that finally allows the surgeon to have complete
control over the entire process and to do it very
quickly.
In terms of surgery, I would love to see a means
of overlaying a CBCT with the patient's actual
anatomy in the OR to enable guided surgery, much
the same as what surgeons are already doing in
implant surgery. Having real-time " X-ray vision "
would give the surgeon complete confidence that
the tip of the saw is always in the right place and an
immediate awareness of the concealed bony interferences
that are often time-consuming to address
during surgery. The last and most important thing
needed to advance all of these protocols is that
the industry needs to figure out a way to introduce
these digital technologies with cost in mind. The
phrase " all dressed up and nowhere to go " really
applies when we have a patient who could benefit
from all these fascinating technologies, but the
added cost prevents us from using it.
Fall 2021 PCSO Bulletin
49
Pacific Coast Society of Orthodontists Bulletin Fall 2021

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Fall 2021
