# Evaluation of Deviations Produced by Soft Tissue Fitting in Virtually Planned Orthopathic Surgery
## 4 Discussion
OQOL scores for surgeries performed were consistent in terms of patient satisfaction and DFD correction. They indicate that all patients were highly satisfied with the outcome of the surgery. Since lower scores indicate greater satisfaction, a mean score of 24.82 is consistent with expected scores following successful surgery [36]. The study aligns with the mean score of 20.53 reported by many studies, leading us to affirm the result [1]. Analysis of grouped OQOL domains by VSP adherence showed that surgeries where the surgeon's criteria drove the final positioning had the same good outcome as those that strictly followed VSP. No difference was observed in either Class II or Class III patients. However, there is concern about an outlier patient who had difficulty understanding the questionnaire. Specifically, oral functionality and social concerns were the best-scoring subdomains, reaching higher satisfaction levels than the average results reported in the literature [36; 37]. This confirms the findings of many studies that social awareness improves the most in DFD patients after OS [4; 38; 39; 40]. Additionally, we must consider the limitations of this study, which were caused by the small sample size. A lack of adherence by many patients, as well as different external \begin{table}
\begin{tabular}{c c c c c} \hline \hline
**Study** & **Sample Size** & **VSP Performance Test** & **Software** & **Deviation** \\ \hline \multirow{3}{*}{[PERSON] et al. (2019) [26]} & \multirow{3}{*}{8} & \multirow{3}{*}{Real surgical application} & PFEM & 1.3 \(\pm\) 0.4 mm \\  & & & Dolphin & 1.8 \(\pm\) 0.8 mm \\  & & & ProPlan & 1.2 \(\pm\) 0.4 mm \\ [PERSON] et al. (2021) [33] & \multirow{3}{*}{35} & Theoretical VSP simulation & \multirow{3}{*}{Lip sliding FEM} & \multirow{3}{*}{0.6 \(\pm\) 0.2 mm} \\  & & for previous surgeries & & \\ [PERSON] et al. (2017) [34] & \multirow{3}{*}{40} & Theoretical VSP simulation & \multirow{3}{*}{3-step FEM with sliding} & \multirow{3}{*}{1.1 \(\pm\) 0.7 mm} \\ [PERSON] et al. (2022) [35] & \multirow{3}{*}{10} & Real surgical application & Adapted FEM & -3 mm \\ [PERSON] et al. (2022) [24] & \multirow{3}{*}{20} & Real surgical application & IPS CaseDesigner® & -2 mm \\ [PERSON] et al. (2023) [25] & \multirow{3}{*}{8} & Theoretical VSP simulation & \multirow{3}{*}{Detailed anatomical FEM (CBCT + RM)} & \multirow{3}{*}{0.55 \(\pm\) 2.9 mm} \\  & & for previous surgeries & & \\ \hline \hline \end{tabular}
\end{table} 
Table 4: Comparative table of studies measuring VSP performance involving soft tissue simulation. factors, resulted in a study of only 11 cases, which is not optimal for statistical analysis. This had a direct impact on statistical power, which was compromised. It is difficult to establish statistical correlations between factors that could affect VSP reliability and precision. Nevertheless, the previously mentioned studies had even fewer participants than our study, with 8-10 patient cohorts, sharing our statistical limitations and issues. In addition, few studies have been found that measure VSP prediction performance in real surgical cases like ours. Others have used theoretical retrospective approaches to test novel methodologies that are not yet ready for clinical application. However, a lack of effectiveness in soft tissue prediction has been demonstrated, especially in Class II patients. Having a large patient cohort would help to reach stronger statistical conclusions, but this is acknowledged as a limitation due to patient enrolment in the service. Furthermore, future research could consider more VSP software incorporating different algorithms for soft tissue prediction.