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. 2019 Jan 17;21(3):221–229. doi: 10.1001/jamafacial.2018.1863

Assessment of a Novel Standardized Training System for Mandibular Contour Surgeries

Jia Qiao 1, Jia Xu 2, Xi Fu 1, Feng Niu 1,✉, Lai Gui 1, Sabine Girod 3, Chung-Kwan Yen 3, Jianfeng Liu 1, Ying Chen 1, Jeffrey W Kwong 3, Cai Wang 4, Huijun Zhang 1, Shixing Xu 1, Hamzah Alkofahi 3, Xiaoyan Mao 1
PMCID: PMC6537852  PMID: 30653220

Key Points

Question

Can use of a novel intraoral training model and surgical templates improve mandibular contour surgery (MCS) training and surgical results?

Findings

This prospective, observational study including 90 patients and 15 fellow physicians, compared the use of (A) an intraoral MCS training system including intraoral MCS training models and surgical templates; (B) the intraoral MCS training models without surgical templates; and (C) standard training as a control group. Use of both interventions decreased clinical surgery time, improved surgical accuracy, and shortened the learning curve compared with the control group, but the use of templates with the intraoral MCS training models was associated with the best results among the 3 groups.

Meaning

The intraoral MCS training system improved MCS training among fellow physicians and surgical outcomes for patients; the optimal intraoral MCS training system included intraoral MCS training models and surgical templates.

This study compared the use of an intraoral mandibular contour surgeries (MCS) training system including intraoral MCS training models and surgical templates, the intraoral MCS training models without surgical templates, and standard training as a control group.

Abstract

Importance

Mandibular contour surgeries (MCS) involving reduction gonioplasty and genioplasty are rewarding for patients with square faces; however, the procedure has inherently difficult clinician learning curves and unpredictable skill acquisitions. To our knowledge, there has been no effective, validated training model that might improve training and surgical outcomes for MCS.

Objective

To establish and evaluate a standardized intraoral MCS training system.

Design, Setting, and Participants

Intraoral MCS training models were constructed by 3-dimensional (3D) skull models covered with elastic head cloths. From April 2016 to April 2018, 90 consecutive MCS patients (30 per group) and 15 craniofacial surgery fellow physicians (5 per group) were enrolled in the prospective observational study. They were randomly divided into intervention groups (A and B) and a control group (C). Intervention groups A and B completed 5 training sessions on the intraoral MCS training models before each clinical case. Group A performed both the model training sessions and clinical surgeries with surgical templates. Control group C had no extra training before clinical surgeries. All groups completed clinical surgery under supervision on 6 patients. The duration of follow-up was at least 3 months postoperatively.

Interventions

Intraoral MCS training models were provided to intervention groups (A and B) before clinical surgeries. Surgical templates were provided to intervention group A both in training sessions and clinical surgeries.

Main Outcomes and Measures

The completion time, surgical accuracy, learning curves, operating confidence, surgical skill, and outcome satisfaction of each procedure were recorded and analyzed with paired t test and 1-way analysis of variance test by blinded observers.

Results

All 90 patients (14 men, 76 women; mean [SD] age, 26 [5] years) were satisfied with their postoperative mandible contours. The intervention groups (A and B), especially the group with surgical templates (A) showed improvements in clinical surgery time (mean [SD], group A 147.2 [24.71] min; group B, 184.47 [16.28] min; group C, 219.3 [35.3] min; P = .001), surgical accuracy (mean [SD], group A, 0.68 [0.22] mm; group B, 1.22 [0.38] mm; group C, 1.88 [0.54] mm; P < .001), learning curves, and operators' confidence and surgical skill.

Conclusions and Relevance

The intraoral MCS training model was effective and practical. The optimal intraoral MCS training system included intraoral MCS training models and surgical templates. The system significantly decreased clinical surgery time, improved surgical accuracy, shortened the learning curve, boosted operators' confidence, and was associated with better acquisition of surgical skills.

Level of Evidence

NA.

Introduction

The mandible plays an important role in a harmonious facial form. In East Asia, a square face with a short, receding chin is regarded as unattractive.1,2,3,4 Mandibular contour surgeries (MCS), including reduction gonioplasty and genioplasty, are tremendously popular and are 2 of the most effective ways to achieve the highly desirable oval and slender facial proportions.2,5,6,7

As a mainstream method, reduction gonioplasty by intraoral approach has advantages, including no cutaneous scar and a low risk of injuring the facial nerves2,3,4,7; however, this technique provides limited operating field exposure and restricted operating space.8 Consequently, visualization of the deep mandibular angle and precise bony excess resection can be difficult. When reduction gonioplasty is combined with genioplasty, creating a smooth and natural mandibular lower rim is key to achieving a satisfactory outcome, but this is challenging even for experienced attending physicians. Overall, this surgical technique has a steep learning curve and its training results vary.

Mandibular contour surgeries have become intimidating procedures for aforementioned reasons. In the modern cosmetic surgery era, there is an urgent need for an effective teaching and training alternative. However, to our knowledge, there has not been research attempting to create and validate an intraoral MCS training model in the past 2 decades. The lack of an effective training model impedes not only the achievement of optimal surgical results, but also the development of aesthetic craniofacial surgery as a subdiscipline.

Computer-aided design (CAD) and computer-aided manufacture (CAM) technologies9,10 have been great improvements in virtual reality and surgical design11,12,13,14,15,16,17,18 recently. Surgical templates for MCS can help to achieve higher surgical accuracy. However, the clinical effectiveness of these templates has not yet been verified.

The purpose of this study is to introduce and assess the effectiveness of our intraoral MCS training model, determine the validity of surgical templates, and create an optimal intraoral MCS training system.

Methods

Participants

From April 2016 to April 2018, 90 patients who intended to have reduction gonioplasty and genioplasty were prospectively enrolled in the observational study. Patients with intellectual disabilities, temporomandibular joint disorders, or an existing medical, physical, or mental condition that would impair healing were excluded. All patients had completed written informed consent forms. Clinical data were collected before and 3 months after the procedure from all patients. This study was approved by the institutional review board of the Plastic Surgery Hospital, Chinese Academy of Medical Sciences.

Fifteen craniofacial surgery fellow physicians who had finished traditional clinical training sessions were selected. The traditional clinical training sessions require the trainees to have been trained in craniofacial for 1 year and have the experience of being first assistant on 10 to 15 MCS cases.

Study Design

The 15 fellow physicians were randomly divided into 3 groups of 5 fellow physicians. The 90 patients were randomly divided into 3 groups of 30 patients. Group A and group B were intervention groups, and group C was the control group. All 90 patients received CAD before surgery. In intervention groups (A and B), fellows performed 5 training sessions on intraoral MCS training models before the clinical surgeries. In group A, both the model training and clinical surgeries were done with the assistance of surgical templates. In the control group, fellow physicians had no extra training before clinical surgeries. All clinical surgeries were done under the supervision of senior attending physicians (L.G. and F.N., among other nonauthors). Each fellow physician performed MCS on 6 patients (Figure 1).

Figure 1. Study Flowchart.

Figure 1.

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3D Indicates 3 dimensional; MCS, mandibular contour surgery.

Parameters

All patients took front and lateral facial photographs, cephalometric radiographs in the central occlusion position, and a computed tomographic (CT) scan of the head in the supine position (Brilliance CT 64 Slice, Philips Medical Systems), before and after surgeries. All MCS 3D skull models underwent CT before and after model surgery. The image slice thickness for the reconstructed images was 1 mm, the image matrix size was 512 × 512, and the pixel size was approximately 0.3 mm. We printed 5 3D skull models for each patient in experimental groups A and B. Three sets of surgical templates (Jike3 Medical Imaging Technical Services Corporation, LTD) were printed for each procedure in group A.

Preoperative Design

The aesthetic of the whole face and each independent part were carefully evaluated using facial photographs and cephalograms. The standardized surgical plan and CAD and CAM for the surgical templates were done as described in our previous publication12,19 (eFigures 1 and 2 in the Supplement).

Intraoral MCS Training Model

The intraoral MCS training model was established by using a 3D skull model covered with an elastic head cloth (Hume) (Figure 2A). The 3D skull models and templates (eFigure 3 in the Supplement) were made of photosensitive resin material (med 610), which were printed using the Z Printer 350 (Z Corporation).

Figure 2. Operating Procedure of Group A in Training Sessions.

Figure 2.

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Operating procedure of group A in training sessions. A, Intraoral MCS training model consisted of a 3D skull model covered with an elastic head cloth. B, Mandibular angle templates with an unicortical screw for rigid fixation were applied in intraoral MCS training model, whereas the osteotomy line could be marked along the template’s margin with a dental drill. C, Mandibular outer cortex above the marking line was burred by a large grinding ball after removing the template. D and E, based on the markings, the curved osteotomy of mandibular angle excess was resected with an oscillating saw and chisels. F, Resulting resected mandibular angle segments covered with surgical templates are shown. G, Cutting template was fixed onto the chin bone to guide the reciprocating saw blade in intraoral MCS training model. H, Fixation template determined the 3D position of the distant chin bone. I, Internal rigid fixation with the titanium miniplates and screws. J, Postoperative intraoral MCS training model. 3D indicates 3 dimensional; MCS, mandibular contour surgery.

Model Surgery

Surgeries were performed with 1 main surgeon and 2 assistants, as done in clinical surgeries. Fellow physicians in group A performed model surgeries with surgical templates. First, the ramus below the occlusal plane, the angle, and the body posterior to the mental foramen were exposed. Second, the mandibular angle templates were applied with an unicortical screw for rigid fixation (Figure 2B). The margin along the template was marked as the osteotomy line using a dental drill. After removing the template, the outer cortex of the mandible above the marking line was burred down by a large grinding ball (Figure 2C) and the bony excess in the mandibular angle was resected with an oscillating saw (Figure 2D) and chisels (Figure 2E) along the markings. The resulting resected mandibular angle segments covered with surgical templates are shown in Figure 2F. Third, the cutting template guided the osteotomy was fixed onto the chin bone as planned (Figure 2G). After a horizontal osteotomy, chisels were used to separate the bony segments. The fixation template was used to determine the 3D position of the distant bone segment (Figure 2H). Fourth, titanium miniplates and screws were used for internal rigid fixation (Figure 2I). Finally, both sides of the bony step-off caused by advancement of the segment were burred down to smoothness (Figure 2J and Figure 3A).

Figure 3. Lateral View of Intraoral MCS Training Model Postoperatively and Registration Between the CAD and Postoperative CT in Clinical Cases.

Figure 3.

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A, The lateral view of intraoral MCS training model postoperatively in group A and (B) in group B. Surgical accuracy (relative errors) was evaluated by registration between the CAD and postoperative CT. The 3D comparison was calculated by Geomagic automatically. 4 types of errors were calculated: 1. Average relative error, the mean value of discrepancy between postoperative CT and preoperative CAD on the entire mandible; 2. Go’-L error, discrepancy between postoperative CT and preoperative CAD at left new gonial point; 3. Go’-R error, discrepancy between postoperative CT and preoperative CAD at right new gonial point; and 4. Pg error, discrepancy between postoperative CT and preoperative CAD at pogonion. C, The registration results of clinical case from group A, group (D) B, and group (E) C are shown. CAD indicates computer-aided design; CT, computed tomography; 3D, 3 dimensional; MCS, mandibular contour surgery.

Fellows in group B performed model surgeries without surgical templates (Figure 3B). Details on clinical surgeries are presented in the eAppendix in the Supplement and Figure 4.

Figure 4. Surgical Images.

Figure 4.

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A, The mandibular angle templates were applied in clinical gonioplasty. B, The cutting template of the chin was applied in clinical genioplasty to guide the osteotomy line. C, The fixation template determined the 3-dimensional position of the distant chin bone in clinical genioplasty.

Main Outcomes and Measures

The surgery time begins with the exposure of the mandible and ends just before the closure. Complications were recorded.

The surgical accuracy of the 3D skull models and the clinical surgery outcomes were analyzed each time by comparing preoperative CAD and postoperative CT. The 3D comparison was calculated by Geomagic automatically (version 12.0, Geomagic Studio). Four types of errors were calculated: (1) average relative error, the mean value of discrepancy between postoperative CT and preoperative CAD on the entire mandible; (2) Go’-L error; (3) Go’-R error; and (4) Pg error, discrepancy between postoperative CT and preoperative CAD at left new gonial point/right new gonial point/pogonion (Figure 3, C-E).

The learning curve for all participants were recorded. A learning curve is a graphical representation of learning progress. We used 2 indicators in our study: surgical time and surgical accuracy. The number of sessions is on the horizontal axis, and the 2 indicators are on the vertical axis.

All 15 fellows rated their level of operating confidence of the clinical cases and satisfaction of the intraoral MCS training models using a Likert scale (1, very unconfident/very unsatisfied; 5, very confident/very satisfied). All supervisors rated fellow physicians’ surgical skills on a Likert scale (1, very poor; 5, very good). All patients rated their satisfaction of their surgical outcome on a Likert scale (1, very unsatisfied; 5, very satisfied).

All data were collected and analyzed by blinded observers. Paired t test and 1-way analysis of variance test (adjusted P value with least significant difference [LSD] method) were used to determine the differences in surgical time and accuracy among groups. Analyses were carried out using Statistical Package for the Social Sciences statistical software (version 19, IBM). Values of P < .05 were considered significant. Values of P < .001 were considered highly significant.

Results

Fourteen men and 76 women ranging in age from 18 to 48 years (mean [SD],26.33[5.24] years) were enrolled in the study. There were no complications, such as visible scars, hematomas, wound dehiscence, infections, or long-term neurosensory disturbances in our series. Seven patients reported local numbness lasting no more than 4 months. All patients reported short-term, minor symptoms postoperatively, such as swelling and mild pain. All symptoms disappeared completely within 2 to 4 weeks.

The surgical mean (SD) time of MCS on the intraoral MCS training model was significantly lower in group A (49.66 [12.38] mins) than in group B (65.49[13.76] mins) (95% CI, −17.07 to −14.58; P < .001). The mean (SD) surgical time of clinical MCS was significantly different among the groups (group A,147.2 [24.71] min; group B, 184.47 [16.28] min; group C, 219.3 [35.3] min; P = .001). With LSD method, there was significant difference between groups A and B (95% CI, −69.99 to −4.54; P = .03), B and C (95% CI, −67.56 to −2.11; P = .04), there was highly significant difference between groups A and C (95% CI, −104.82 to −39.38; P < .001). The time of the intervention groups was shorter than that of the control group. Among the intervention groups, group A had shorter time than group B.

The mean (SD) surgical accuracy of MCS on the intraoral MCS training model was higher in group A than in group B (Figure 5), which can be seen in the relative error of the entire mandible (group A, 0.7 [0.14] mm; group B, 1.28 [0.26] mm; 95% CI, −0.64 to −0.53; P < .001), the Go’-L error (group A, 0.24 [0.08] mm; group B, 1.24 [0.53] mm; 95% CI, −1.16 to −0.84; P < .001), the Go’-R error (group A, 0.31 [0.06] mm; group B, 1.33 [0.42] mm; 95% CI, −1.14 to −0.91; P < .001), and the Pg error (group A, 0.58 [0.09] mm; group B, 1.82 [0.42] mm; 95% CI, −1.34 to −1.13; P < .001).

Figure 5. Learning Curves.

Figure 5.

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A learning curve is a graphical representation of learning progress. We used 2 indicators in this study, surgical time (A and B) and surgical accuracy (C and D). The number of sessions is on the horizontal axis, and the 2 indicators are on the vertical axis. MCS indicates mandibular contour surgery.

The surgical accuracy of the clinical MCS was significantly different among the groups. The mean (SD) relative error of the entire mandible (group A, 0.68 [0.22] mm; group B, 1.22 [0.38] mm; group C, 1.88 [0.54] mm; P < .00;), the Go’-L error (group A, 0.21 [0.11] mm; group B, 0.98 [0.31] mm; group C, 1.81 [0.58] mm; P = .001), the Go’-R error (group A, 0.35 [0.09] mm; group B, 1.12 [0.13] mm; group C, 1.83 [0.37] mm; P = .001), the Pg error (group A, 0.62 [0.13] mm; group B, 1.27 [0.29] mm; group C, 2.21 [0.59] mm; P = .001) are all shown in eTable 1 in the Supplement. With LSD method, there was significant difference between groups A and B (95% CI, −0.99 to −0.86; P = .02), groups B and C (95% CI, −1.11 to −0.21; P = .007), groups A and C (95% CI, −1.65 to −0.75; P < .001) in relative error of the entire mandible. The intervention groups had higher surgical accuracy than that of the control group. Within the intervention groups, group A had higher accuracy than group B.

The learning curve with surgical time as indicator showed fellow physicians from all groups had a drastic reduction in surgery time as the number of procedures increased both in intraoral MCS model trainings and clinical surgeries. A plateau stage occurs at earlier stage and has a shorter surgical time in the intraoral MCS model trainings of group A. In clinical surgeries, group C had the longest initial surgical time and approached a plateau stage later. Its plateau stage still had a longer surgical time than the other 2 groups, the comparison indicating better proficiency for the beginning cases, faster surgical proficiency improvement, and better final proficiency with intraoral MCS training model (intervention groups). Within the intervention groups, group A had shorter initial surgical time and steeper learning curve slope than group B, indicating the best proficiency for the beginning cases, the fastest surgical proficiency improvement, and the best final proficiency with intraoral MCS training model and surgical templates (Figure 5).

The learning curve with surgical accuracy as the indicator presented a decreasing trend with the entire mandible average relative error in all groups in both intraoral MCS training models and clinical surgeries, which means more accurate surgical results were achieved as the number of procedures increased. In intraoral MCS training models training, group A showed more stable and less relative error (more accurate) than group B. In clinical MCS, the initial and final surgical accuracy was higher in intervention groups, the highest in group A using surgical templates. Meanwhile, group A showed the most stable surgical accuracy. Indicating the highest and the most stable surgical accuracy with intraoral MCS training model and surgical templates (Figure 5).

Scores of fellow physicians’ satisfaction of intraoral MCS training model showed all fellow physicians were satisfied with the intraoral MCS training model. The mean (SD) satisfaction score for group A (4.87 [0.36]) was higher than in group B (4.69 [0.74]) (95% CI, 0.29-0.41; P < .001). There was no statistical difference of fellow physicians’ confidence in operating clinical cases (group A, 4.68 [0.21]; group B, 4.39 [0.17]; and group C, 3.95 [0.84]; P = .08), whereas with the LSD method, fellow physicians in group A reported more confidence than those in group C (95% CI, 0.09-1.37; P = .03). Scores of fellow physicians’ surgical skills varied between group A (4.77 [0.11]), group B (4.52 [0.51]), and group C (4.04 [0.23]) (P = .004). All patients were satisfied with their facial contours after surgery (eTable 2 and eFigure 4 in the Supplement). Scores of patients’ satisfaction of surgical outcomes were significantly higher in group A (4.85 [0.48]) and group B (4.46 [0.34]) than in group C (4.22 [0.75]) (P = .03), and patients in group A were significantly more satisfied than those in group C (95% CI, 0.17-1.10; P = .01) (eTable 2 in the Supplement).

Discussion

Mandibular contour surgery can improve the mandibular contour and is the most popular aesthetic craniofacial surgery in East Asia.2,3,4,5,6,7,8 The intraoral approach with an invisible scar for MCS is widely accepted. Intraoral MCS, however, are difficult. The key lies in creating a smooth and natural mandibular lower rim, when reduction gonioplasty is combined with genioplasty. The difficulties are, first, the visualization is poor. It is hard for experienced physicians to see the operating field, and it is almost impossible for physicians in training. Second, the operating space is narrow. It requires steady and deft hands. Third, the position of the mandibular angle is deep. The compound of these difficulties means a precise resection is difficult. A misplaced osteotomy line could result in mandibular condyle fracture or inferior alveolar nerve damage.4,5,6,8 Intraoral MCS thus require highly skillful and experienced practitioners. Training in such a highly specialized field poses various challenges. Meanwhile, patients often want to be treated by experienced surgeons only.20,21 Given the limited surgical opportunities, the difficulty of surgery itself and the lack of effective training alternatives, training in MCS is often insufficient for resident physicians and fellow physicians. An effective training alternative is needed.

So far, manipulating directly on 3D skull models is the only feasible alternative to train for MCS.8,9,10 It helps surgeons familiarize themselves with patient-specific bone structures before surgery and aid in preoperative planning, but it cannot simulate an intraoral approach. Using human cadaver is the best training model for MCS theoretically, but they are rarely used in Asian countries owing to cultural factors.

Many training alternatives including living animals and nonliving models have been explored in surgical training, yet none of these is appropriate for MCS. Living animals are traditionally considered to be the gold standard in many surgeries.22,23,24 Swine and sheep can be used as models for craniomaxillofacial surgeries such as distraction osteogenesis, mandibular outer cortex split, and bone grafting.25,26,27 However, it is not practical to simulate an intraoral approach. Moreover, using living animals also requires additional financial costs and ethical reviews.

Nonliving simulator models can provide a controlled, risk-free environment. Such models have been used in other surgical fields such as laparoscopy, urology, obstetrics, and microsurgery.21,22,23,24,25,26,27,28,29,30,31,32 Haptic devices with virtual tactile perception were reported in orthognathic surgery33 and facial contour surgery.34 It can simulate cutting, separating, and rearranging bones. Such devices are, however, not yet realistic nor affordable to become mainstream models.33,34

In this study, we introduced the first intraoral MCS training model. It is an effective and affordable nonliving simulator. The elastic cloth is adjustable and fixed on the 3D skull model firmly. The force and compliance from the elastic cloth has a high similarity with the soft tissue. It vividly imitated the limited visualization and restricted operating space. All steps of osteotomy and the unique challenges of intraoral MCS could be easily simulated. All participants report that the model is very effective, and that it highly resembles the actual surgery. Both the elastic cloth and 3D skull model are routinely used in craniomaxillofacial and are readily available. No specially designed software or devices are needed. Thus, this training method is accessible and economical for most centers. The advantages of our technique are listed as follows. First, it can be used as an educational tool for MCS. Second, it can reduce operation time. Third, it can help to produce more accurate and predictable results. Finally, it is affordable and easy to obtain.

To verify the effectiveness of our intraoral MCS training model, we evaluated the difference between the intervention groups (groups A and B) and the control group (group C). Our study has shown that this intraoral MCS training model can significantly improve the training. Fellow physicians trained using our intraoral MCS training models performed surgeries in less time, achieved higher accuracy, acquired higher surgical proficiency, and were more confident of their performance compared with those trained with traditional training only.

To verify the validity of surgical templates for MCS, we evaluated the difference between group A and group B. For both training models and clinical patients, fellow physicians in group A spent less time and achieved more accuracy. Here we combined intraoral MCS training models with surgical templates to establish an optimal intraoral MCS training system, as a standardized educational tool for trainees.

Our intraoral MCS training system significantly improved training quality. This would not only provide excellent patient services, but also favorably represent our specialty in the competitive environment of aesthetic surgery. Our intraoral MCS training model can be used in other intraoral maxillofacial surgeries, transconjunctival approach surgeries, opisthotic approach surgeries, or minimum invasive craniomaxillofacial surgeries. We can also apply virtual and/or augmented reality-assisted maxillofacial surgeries, robotic training,35 or other frontier technologies on our intraoral MCS training system as preclinical tests to check its feasibility and safety.

Limitations

Owing to limited clinical MCS sample size, we were unable to compare the difference of complications between the traditional training group and the intraoral MCS training group. Such differences need to be explored in the future. Our intraoral MCS training system is effective, accessible, and economical. We added an elastic rubber cord to simulate the mental nerve between the elastic cloth and the 3D model in an updated model. However, intraoperative bleeding cannot be simulated, and the rigidity of the 3D-printed skull is weaker than the human skull. In the future robotic surgery era, haptic tactile technique-assisted simulators might become the direction of training.

Conclusions

The overriding goal of this project was to establish a better way to achieve optimal results in training plastic surgery resident physicians and fellow physicians. We thus invented and assessed the effectiveness of an intraoral MCS training model, verified the validity of surgical templates on MCS surgeries, and established an optimal intraoral MCS training system, which includes intraoral MCS training models and surgical templates, as a standardized educational tool for trainees. The system significantly decreased clinical surgery time, improved surgical accuracy, shortened learning curves, boosted operators’ confidence, and achieved better acquisition of surgical skills. It is simple, economical, and can significantly improve the training quality of surgical trainees.

Supplement.

eAppendix.

eTable 1. Accuracy analysis by comparison of CAD and post-operative CT

eTable 2. Scores of Patients, Fellows, and Supervisors from Intraoral-MCS-Training Models and Clinical Cases

eFigure 1. Preoperative 3D-skull

eFigure 2. The mandibular angle templates were designed to have inner margins preventing slippage and extended fixation hole making a further stable osteotomy

eFigure 3. The mandibular angle templates

eFigure 4. Clinical Images

Click here for additional data file. (615KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eAppendix.

eTable 1. Accuracy analysis by comparison of CAD and post-operative CT

eTable 2. Scores of Patients, Fellows, and Supervisors from Intraoral-MCS-Training Models and Clinical Cases

eFigure 1. Preoperative 3D-skull

eFigure 2. The mandibular angle templates were designed to have inner margins preventing slippage and extended fixation hole making a further stable osteotomy

eFigure 3. The mandibular angle templates

eFigure 4. Clinical Images

Click here for additional data file. (615KB, pdf)

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