Current orthognathic surgery practices in Taiwan: A questionnaire survey among board-certified oral and maxillofacial surgeons

Abstract

Background/purpose

Orthognathic surgery (OgS) has substantially evolved in Taiwan; however, few comprehensive surveys have been conducted. This study investigated the contemporary clinical landscape and practice patterns of Taiwanese oral and maxillofacial surgeons (OMSs).

Materials and methods

This cross-sectional anonymous questionnaire study, consisting of 48 questions covering 5 major domains, was conducted in Taiwanese OMSs between August 22 and September 8, 2024.

Results

A total of 94 valid responses were collected. 71.28% respondents practiced in medical centers and 52.13% were located in northern Taiwan. Whereas 51.06% of active surgeons performed 1–5 cases annually, a distinct high-volume subgroup (9.0%) performed over 30 cases per year. These high-volume practitioners were distributed across major metropolitan areas, with 50% practicing in medical centers and 50% having 1–10 years of experience. Le Fort I one-piece osteotomy and sagittal split osteotomy with rigid fixation were the predominant surgical approaches, whereas vertical ramus osteotomy with nonrigid fixation was more commonly preferred by senior surgeons. In aesthetic surgery, hard-tissue procedures predominated, particularly isolated mandibular contouring. Regarding postoperative care, shorter hospital stays (2–3 days) and antibiotic courses (<3 days) were commonly observed and were associated with exceptionally low reported infection rates (<1%). Furthermore, more that 90% of the surgeons incorporated three-dimensional digital planning into preoperative workflows.

Conclusion

The orthognathic and aesthetic surgical practices of Taiwanese OMSs generally reflect current global trends. The low reported postoperative infection and complication rates also support the reliability of specialty training in Taiwan. These findings may provide a benchmark for future comparative studies.

Introduction

Orthognathic surgery (OgS) is a cornerstone procedure performed by oral and maxillofacial surgeons (OMSs). The procedure corrects structural abnormalities of the upper and lower jaws to improve occlusal function, maintain airway patency, and enhance facial aesthetics.1 The first mandibular osteotomy performed to correct a protruded alveolar mandible was reported by the American surgeon Simon P. Hullihen in 1849.1–3 Following the 1950s, orthognathic surgical techniques advanced considerably.1–5 According to pioneers in Taiwanese oral and maxillofacial surgery, the OgS began to develop in Taiwan in the 1970s, with procedures such as maxillary anterior subapical osteotomy and extraoral ramus or body osteotomy being implemented. Advances in medical education, surgical techniques, and operative equipment have markedly expanded the scope of OgS in Taiwan. Contemporary orthognathic procedures have become increasingly comprehensive and can effectively address diverse patient needs.6–11 However, few statistical and behavioral surveys have evaluated the current status of OgS practice in Taiwan. Moreover, studies have yet to comprehensively investigate relationships among variables such as surgical technique selection across different health-care settings, postoperative care philosophies, the use of surgical auxiliary equipment, and surgeons’ background characteristics. Obtaining these data would improve the understanding of current clinical practices among OMSs in Taiwan, thereby guiding the future development of clinical training and medical education in Taiwan. To this end, an anonymous, five-domain questionnaire was distributed to certified specialists to collect clinical practice patterns. Through integrated data analysis and cross-sectional comparisons, this study characterizes Taiwan’s current OgS landscape and explores the relationships among key variables.

Materials and methods

Questionnaire design

This cross-sectional study was approved by the Joint Institutional Review Board of Taipei Medical University (TMU-JIRB-N202407091). The questionnaire used in this study was developed by Dr. Chih-Yuan Fang and consisted of 48 questions categorized into the following five domains:

1. Surgeon background information (e.g., years of practice, location, and patient sources)

2. Numbers and types of orthognathic and aesthetic procedures performed, including the frequency of different surgical techniques

3. Surgical preferences and postoperative care concepts (e.g., fixation methods, antibiotic administration, and length of hospital stay)

4. Surgical planning tools and operative equipment used (e.g., articulators, three-dimensional (3D) planning techniques, and piezoelectric instruments)

5. Postoperative complications and patient feedback (e.g., revision surgery and postoperative infection)

Participants

The target participants were specialists certified in oral and maxillofacial surgery by the Ministry of Health and Welfare, Taiwan. Individuals were considered eligible for participation if they were actively engaged in OgS practice and voluntarily completed the survey. In Taiwan, becoming an OMS requires completion of a Bachelor of Dental Surgery degree as well as a 2-year postgraduate year residency training program. Prospective surgeons must then complete an additional 3.5 years of advanced specialist training and pass the national certification examination to obtain specialist certification.

Data collection

The survey was conducted between August 22 and September 8, 2024. The online questionnaire was distributed through professional social media groups composed of TAOMS specialists over a period of approximately two weeks.

Results

A total of 94 valid questionnaires were collected. According to data from the Ministry of Health and Welfare, approximately 441 certified OMSs were practicing in Taiwan in 2024, of whom approximately 100 were actively performing OgS. The 94 responses collected in this study therefore represent the vast majority of active OgS practitioners in Taiwan, supporting the representativeness of the collected data. The following sections summarize our findings:

Surgeon profiles and backgrounds

The distribution of the respondents on the basis of their demographic characteristics, clinical experience, and annual surgical volume is summarized in Table 1. 71.28% respondents practiced in medical centers, followed by regional hospitals (20.21%). 52.13% respondents were located in northern Taiwan, followed by southern and central Taiwan. Regarding years of practice experience, surgeons with 1–10 years of experience represented the largest group (41.49%), followed by those with 11–20 years (39.36%), 21–30 years (10.64%), and >30 years (8.51%) of experience.

Table 1.

Demographic characteristics, clinical experience, and annual surgical volume of respondents. In the geographic distribution section, the total number of practice locations reported (n = 96) exceeded the total number of respondents (n = 94) because some surgeons practiced in multiple regions (e.g., one surgeon practiced in both Taipei and Tainan, whereas another practiced in both Tainan and Kaohsiung) and each practice location was counted separately for these respondents.

Institution	Number of surgeons	Percentage (%)
Medical center	67	71.28
Regional hospital	19	20.21
District hospital	3	3.19
OMS clinic	3	3.19
Plastic surgery clinic	2	2.13
Total	94	100
Practice location	Number of surgeons	Percentage (%)
Northern Taiwan	49	51.04
Central Taiwan	23	23.96
Southern Taiwan	24	25.0
Total	96	100
Years of clinical experience	Number of surgeons	Percentage (%)
1–10 years	39	41.49
11–20 years	37	39.36
21–30 years	10	10.64
>30 years	8	8.51
Total	94	100
Number of orthognathic surgical cases per year	Number of surgeons	Percentage (%)
0	8	8.51
1–5	48	51.06
6–12	17	18.09
13–30	13	13.83
>30	8	8.51
Total	94	100

Numbers of orthognathic and aesthetic procedures

Regarding the annual volume of OgS procedures, 86 respondents reported actively performing such procedure. The eight respondents who did not perform OgS were excluded from subsequent analyses. Most surgeons performed 1–5 OgSs annually (51.06%, n = 48), followed by 6–12 (18.09%, n = 17) and 13–30 (13.83%, n = 13). Additionally, 8 (9.0%) surgeons reported performing more than 30 OgSs annually, indicating that a substantial proportion of the surgical volume was concentrated among a small subgroup of high-volume practitioners. Further analysis of these 8 high-volume surgeons (>30 cases/year) revealed the following:

(1) Type of health-care institution

Among these surgeons, four practiced in medical centers, two practiced in oral and maxillofacial surgery clinics, one practiced in a plastic surgery clinic, and one practiced in a regional hospital. These findings indicate that although the high-volume surgeons were mainly based in medical centers, they were also represented in other healthcare settings.

(2) Geographic distribution

Taipei had the highest concentration of high-volume surgeons (n = 3), followed by Tainan City (n = 2). Taichung City, Kaohsiung City, and Changhua County each had one high-volume surgeon. This indicates that the high-volume surgeons were mainly concentrated in major metropolitan areas, particularly in the six municipalities of Taiwan, with a slight predominance in northern Taiwan.

(3) Years of specialty experience

Four surgeons had 1–10 years of specialty experience, two had 10–20 years, and two had 20–30 years of experience. These findings suggest that the practitioners with high surgical volume had multiple experience levels, and no clear association was present between longer experience and higher surgical volume.

Surgical preferences

The surveyed surgeons’ preferences for surgical techniques are summarized in Table 2. Regarding maxillary procedures, the respondents reported high utilization rates for both Le Fort I one-piece and Le Fort I multipiece osteotomies. Notably, the annual surgical volume for Le Fort I one-piece osteotomy was significantly higher (P < 0.01), with most surgeons performing 1–5 surgeries per year. By contrast, fewer surgeons performed anterior subapical osteotomy (ASO) without concurrent Le Fort I osteotomy. Most respondents reported performing fewer than five ASO procedures annually, and a significant proportion reported not performing the procedure at all.

Table 2.

Annual surgical volume distribution of specific orthognathic procedures among respondents.

	Surgical procedure	0 cases	1–5 cases	6–12 cases	13–30 cases	>30 cases
Maxillary procedures	Le fort I one-piece osteotomy	13	53	11	12	5
	Le fort I multiple-piece osteotomy	37	47	5	2	3
	Anterior subapical osteotomy (Not combined with Lefort I)	57	35	2	0	0
Mandibular procedures	IVRO/BIOO	49	25	11	6	3
	BSSO	14	48	13	12	7
	Köle procedure	76	16	1	1	0

Abbreviations: IVRO, intraoral vertically ramus osteotomy; BIOO, bilateral intraoral oblique osteotomy; BSSO, bilateral sagittal split osteotomy.

Regarding mandibular procedures, bilateral sagittal split osteotomy (BSSO) was the most commonly preferred technique. Most surgeons performed one to five annually, whereas some performed more than six per year. By contrast, intraoral vertical ramus osteotomy (IVRO) was performed considerably less frequently, with more than half of the respondents reporting either not performing the procedures or having very limited experience with them. Hybrid procedures (e.g., BSSO on one side combined with IVRO on the other side) and the mandibular Köle procedure were even less common. Most surgeons reported performing fewer than one to five procedures annually or not performing these procedures at all. The low surgical volume observed for these procedures was similar to that noted for ASO. The specific indications for the mandibular Köle procedure likely limit the number of patients eligible to receive it. In addition, only a limited number of surgeons routinely perform this technique. Thus, the responses of “rare” or “none” were common.

Aesthetic surgery

As presented in Table 3, isolated malarplasty or zygomaplasty, OgS combined with mandibular contouring (V-line surgery), and isolated mandibular contouring were the most commonly performed aesthetic procedures. These procedures were performed more frequently than soft-tissue aesthetic procedures were. Specifically, 13 surgeons performed zygomaplasty, with most (n = 11) performing 1–5 procedures annually and only a few performing more than 6 annually. A higher number of surgeons (n = 35) performed OgS combined with mandibular contouring. Among these surgeons, 22 performed 1–5 annually, whereas 10 performed 6 or more annually. Isolated mandibular contouring was performed by 21 surgeons, with most reporting performing 1–5 annually and only a few performing more than 12 annually.

Table 3.

Numbers of surgeons performing aesthetic-related procedures and corresponding annual case volume.

Procedure type	Number of surgeons	Annual surgical cases
		1–5 cases	6–12 cases	13–30 cases	>30 cases
Malarplasty	14	11	1	1	1
Orthognathic surgery with genioplasty and mandibular contouring	35	22	5	5	3
Isolated mandibular contouring	21	16	3	0	2
Procedure type	Number of surgeons who performed the procedure		Number of surgeons who did not perform the procedure
Rhinoplasty	6		88
Blepharoplasty (double eyelid surgery)	2		92
Facial liposuction	11		83
Facelift (rhytidectomy)	7		87

A smaller subset of respondents reported experience with other aesthetic procedures, including rhinoplasty (n = 6), blepharoplasty (n = 2), localized facial liposuction (n = 11), and rhytidectomy (n = 7). These findings suggest that OMSs in Taiwan primarily focused on hard-tissue procedures within the field of aesthetic surgery.

Fixation method and duration

In maxillary orthognathic procedures, including Le Fort I and subapical osteotomy, most surgeons (89 of 94) preferred rigid internal fixation using plates and screws, and wire fixation was used less frequently. In mandibular procedures, IVOR techniques primarily involved nonrigid fixation. Forty-nine surgeons reported using intermaxillary fixation with wires, whereas only eight used plates and screws for fixation. By contrast, BSSO was mainly performed using rigid fixation with plates and screws (86 of 94 surgeons). For genioplasty, the fixation methods were more diverse; however, the use of plates and screws was still the most common approach to fixation. Additional details are provided in Table 4.

Table 4.

Distribution of IMF duration and fixation methods after surgery. Hybrid fixation refers to the combined use of bone plates and screws with wire fixation, including K-wire fixation in IVRO/BIOO.

Duration of IMF Number of surgeons	None (unless complications such as bad split occur)	≤2 weeks	2–4 weeks	4–6 weeks	>6 weeks
	46	20	5	14	1
Number of surgeons	Fixation method	Plates and screws	Wire fixation	Hybrid fixation	I did not perform this surgery
	(Maxilla) Le fort I/subapical	89	5	0	0
	(mandible) IVRO/BIOO	8	49	3	34
	BSSO	86	5	0	3
	Genioplasty	61	11	18	4

Abbreviations: IMF, intermaxillary fixation; IVRO, intraoral vertically ramus osteotomy; BIOO, bilateral intraoral oblique osteotomy; BSSO, bilateral sagittal split osteotomy.

Antibiotic administration

The duration of antibiotic administration is summarized in Table 5. The most common practice was administering antibiotics for 4–7 days postoperatively (n = 44). However, nine surgeons administered antibiotics only during the preoperative and intraoperative periods, without administering them postoperatively. Additionally, 17 surgeons prescribed postoperative antibiotics for 72 h, 15 prescribed them for 48 h, and 9 prescribed them for a single postoperative day. Although the 4–7-day regimen represented the largest individual group (n = 44), the cumulative number of surgeons prescribing antibiotics for ≤3 days (n = 50) exceeded the number using the 4–7-day protocol.

Table 5.

Distribution of postoperative antibiotic prophylaxis duration, length of hospital stay, and infection rates. Although the 4–7-day regimen represented the largest individual group (n = 44), the cumulative number of surgeons prescribing antibiotics for 3 days or fewer (n = 50) exceeded the number using the 4–7-day protocol. These findings suggest a gradual shift toward shorter prophylactic antibiotic durations in clinical practice.

Duration of antibiotic administration	Number of surgeons
Preoperative and intraoperative only (none postoperatively)	9
24 h	9
48 h	15
72 h	17
4–7 days	44
Postoperative infection rate	Number of surgeons
Never occurred	37
<1%	41
1%–5%	15
6%–10%	1
Duration of postoperative hospital stay	Number of surgeons
1-night stay	12
2–3 days	61
4–5 days	20
6–7 days	1
Total	94

Most surgeons reported a typical postoperative hospital stay of 2–3 days after OgS (n = 61). The second most common duration of hospitalization was 4–5 days (n = 20). Additionally, 12 surgeons reported that patients were commonly discharged on the first postoperative day after an overnight stay, and 1 reported a hospital stay of 6–7 days.

Presurgical planning and surgical instruments

As presented in Table 6, more than 97% of the surgeons had incorporated 3D computer simulation into preoperative assessment, and 77% reported using intraoral scanning. Regarding surgical instrumentation, approximately 70% of the surgeons preferred a combination of traditional power instruments and piezoelectric ultrasonic bone saws, which has become the predominant instrumentation approach in OgS. Only 41.9% of the surgeons used cutting guides. For determining the facial midline, most surgeons (n = 38) preferred using soft-tissue landmarks, such as the nasal tip or philtrum. A notable proportion of the respondents (n = 34) selected the skeletal midline, defined as the perpendicular line bisecting the interorbital distance on computed tomography images. The remaining surgeons used either the optimal symmetry plane generated by specialized software (n = 11) or the neutral head position (n = 11) as their reference.

Table 6.

Clinical practice patterns and equipment utilization in preoperative planning among oral and maxillofacial surgeons according to years of clinical experience.

Years of experience	1–10 years	11–20 years	>20 years	Total
Preoperative assessment and planning tools
2D radiographic + 3D simulation (no articulator)	18	17	9	44
3D simulation only (no 2D/paper-based)	11	12	2	25
2D radiographic + articulator + 3D simulation	5	3	7	15
2D radiographic + articulator only	1	1	0	2
Dental arch data acquisition
Impression + intraoral scanning	15	17	10	42
Impression only	9	6	6	21
Either impression or intraoral scanning	5	7	0	12
Intraoral scanning only	6	3	2	11
Presentation of bone or soft-tissue simulation to the patient
Presented all simulation	21	18	9	48
Presented bone simulation only	8	8	2	18
Simulation performed but not presented	4	5	5	14
No 3D simulation performed	2	2	2	6
Preferred osteotomy instrumentation
Electric or air-driven drill and saw only	8	13	4	25
Ultrasonic bone surgery (piezosurgery) only	1	0	0	1
Combined	26	20	14	60
Routine use of auxiliary tools (multiple choice)
No routine auxiliary tools	18	19	14	51
Surgical cutting guides	19	12	5	36
Intraoperative computed tomography (hybrid room)	3	2	0	5
Endoscopy	1	2	0	3
Navigation systems	1	2	0	3

For “Routine Auxiliary Equipment,” multiple responses were permitted; therefore, the cumulative count may exceed the total number of respondents performing orthognathic surgery (n = 86).

Postoperative complications and patient feedback

In our survey, postoperative infection rates were categorized into four ranges: never, <1%, 1%–5%, and 6%–10%. Most surgeons reported a postoperative infection rate of <1% (n = 41) or no infection (n = 37), followed by infection rates of 1%–5% (n = 15). One 10-year-experience surgeon who reported performing 1–5 OgSs annually reported an infection rate of 6%–10%. Regarding surgical outcomes, 24 of 94 surgeons reported that patients had either required or requested revision surgery because of aesthetic dissatisfaction. By comparison, only 13 surgeons reported reoperations performed at the request of the treating orthodontist. Furthermore, 39 surgeons believed that revision surgery was clinically warranted because of various factors such as sub-optimal aesthetic outcomes or malocclusion, regardless of whether a second procedure was ultimately performed.

Discussion

Most orthognathic surgeons included in the present study practiced in medical centers and were primarily located in northern Taiwan. Most respondents had between 1 and 10 years of clinical experience. The decreasing number of surgeons across progressively longer experience categories suggests that OgS cases are becoming increasingly concentrated among a small number of highly specialized surgeons. Among the surgeons performing more than 30 OgSs annually, half had only 1–10 years of practice experience. This finding suggests that seniority is not the primary determinant.

Le fort I one-piece osteotomy and BSSO with rigid fixation were the main surgical approaches preferred in this survey, and surgeons who preferred IVRO tended to have longer clinical experience. Because historical data regarding surgical preferences in Taiwan are limited, the timing of this shift in surgical trends remains unclear. Nevertheless, this study could provide foundational benchmark data for future comparative research.

Regarding aesthetic procedures, hard-tissue mandibular surgeries were performed significantly more frequently than other aesthetic or soft-tissue procedures were. Isolated mandibular contouring was the most commonly performed aesthetic procedure among the surveyed surgeons. The significantly high number of surgeons performing malarplasty (n = 13) and mandibuloplasty (n = 21), in addition to procedures such as rhinoplasty and facial liposuction, reflects growing expertise and evolving roles of OMSs in aesthetic surgery.

Strict regulations in Taiwan limit postoperative antibiotic administration to infected or contaminated wounds; however, extended antibiotic courses remain common in clinical practice. Our survey data indicate a division in practice patterns: although 50 surgeons prescribed antibiotics for fewer than 3 days, a 4–7-day regimen (n = 44) remained prevalent in clinical practice. Beyond national policies, other studies have suggested that the optimal duration of postoperative antibiotic administration after OgS continues to be a subject of debate and requires further empirical validation.12–15 For example, Tang et al. reported that a 1-day antibiotic regimen resulted in lower infection rates than a single-dose regimen did, whereas other studies observed no significant difference between treatment durations. Notably, several studies have reported infection rates as high as 12%, which is substantially higher than rates generally considered clinically acceptable. In the present study, the results regarding infection rates were considerably more favorable, with most surgeons reporting rates below 1% or no infections at all. This observation might be attributable to the low surgical volume reported by most respondents, with the majority performing fewer than five procedures annually. Given that complication rates did not significantly vary by antibiotic treatment duration in this study, our findings suggest a clinical trend in Taiwan toward shorter antibiotic courses and hospital stays.

More than 90% of the surgeons in this study had incorporated 3D computer simulation into preoperative planning, with a hybrid “2D X-ray + 3D simulation” approach being the most common strategy (used by approximately 50% of the surgeons). Younger surgeons with 1–10 years of experience drove the transition toward digital workflows, with these surgeons having the highest rates of exclusive intraoral scanning (17.1%) and routine use of cutting guides (54.3%). By contrast, surgeons with >20 years of experience maintained more traditional workflows, relying more heavily on articulators (38.9%) and less frequently adopting advanced surgical aids (77.8%). Notably, the combined use of power saws and ultrasonic bone scalpels (60%–77%) remained common across all experience levels, suggesting a clear generational transition toward fully digital workflows in OgS.

This study has two main limitations. First, the lack of national statistics prevented determining the exact number of OMSs performing OgS in Taiwan, potentially affecting generalizability. Second, collecting age and case volumes in categorical ranges rather than discrete values restricted precise tracking of individual outcomes, averages, and detailed statistical correlations. Despite these limitations, this study establishes a critical benchmark for Taiwan’s OgS trends, providing a foundation for future prospective research and a vital reference for refining specialty education and clinical training.