The umbrella term Dentofacial deformities (DFD) identifies a group of dental and skeletal alterations that result in alterations in the relationship between the jaws, causing unattractive facial features and occlusal impairment (1, 2). Research indicates that 35% of the population has normocclusion, 60% suffer from moderate to severe malocclusion, and 5% have severe dentofacial deformities, including cases in syndromic patients. In particular, 75% of children between 6 and 12 years old and 88% of teenagers between 12 and 17 years old have a malocclusion. This means that it is a worsening problem, which does not improve with the passing of time and the growth (3). But malocclusion should not be considered only a dental or aesthetic problem, as a general problem that affects several features. In fact DFD is a complex disease, considering respiratory, eating and psychological disorders (4–6). Issues such as obstructive sleep apnea are frequently linked to dento-skeletal malocclusion, which narrows the upper airway excessively. A retracted chin position, for example, can restrict air passage due to this malocclusion. Therefore, managing the upper airways has become a crucial aspect of bimaxillary repositioning surgery (7, 8). Another important aspect to consider is feeding, because these patients frequently present eating disorders (9). Moreover, this condition significantly impacts the quality of life, due to the patients' perception to be less attractive, and, consequently, to have lower chances of being socially acceptable and to live a successful life (3–5). Thus, although surgical treatment is the mainstay of DFD treatment, a multidisciplinary approach involving several health professionals, maxillofacial surgeon, orthodontist, nutritionist, psychologist/psychiatrist, speech therapist, is required to manage this complex pathology (5–7).

While Computer-aided design (CAD) and Computer-aided manufacturing (CAM) technologies have revolutionized DFD surgical planning and treatment (10–13), computer technologies still have a minor role in the diagnosis and management of the complex symptoms that accompany facial deformities or complicate their surgical treatment, such as psychological or nutritional problems. This can be due to the lack of a standardized and individualized multi-specialistic care pathway to optimize the comprehensive management of the unmet needs of DFD patients both pre- and post-operatively (13, 14). Nonetheless, over the past two decades, Information and Communication Technology (ICT), including artificial intelligence, mHealth, and telemedicine, has steadily gained importance to address similar issues in routine clinical practice. These technologies provide innovative communication methods and efficient organizational strategies (15). To facilitate the implementation of these ICT interventions also though a detailed identification of patients' needs, in recent years, the Blueprint “Personas” methodology has been developed as a tool for promoting person-centered care. This methodology identifies typical profiles of patients affected with specific diseases, which include information about socio-economic status, personal, health and environment (home setting) needs, and computer literacy so that digital technologies can be implemented and leveraged to obtain personalized care pathways. This methodology has been successfully adopted in other healthcare contexts, such for metabolic syndrome, obstructive apnea syndrome and pulmonary diseases, burning mouth syndrome and cardiovascular congenital defects (16, 17). Starting from these considerations, the objective of our study is to identify the unmet needs of patients with DFD by using the Blueprint persona approach, and to propose digital solutions, based on Information and Communication Technology (ICT), that can help patients meet these needs by improving the diagnostic-therapeutic pathway.

A nice facial appearance depends on the harmony of craniofacial components. Any growth phase alterations can lead to dento-skeletal or dento-facial deformities, characterized by improper relationships between teeth and supporting structures. These issues cause functional and aesthetic problems, with psychological impacts, especially in adolescents. Research shows that 35% of the population has normocclusion, 60% has moderate to severe malocclusion, and 5% has severe deformities, including syndromic cases. Normally, the tongue and muscles create balanced forces between the dental arches, but malocclusion disrupts this balance. Attention is growing on respiratory dynamics in patients with dentofacial deformities, as conditions like obstructive sleep apnea often correlate with malocclusion, which narrows the airway (8, 21–23). Managing the upper airways is key in bimaxillary repositioning surgery. Corrective surgery aims to reposition the maxillary bases, restore occlusion, improve masticatory function, harmonize facial proportions, ensure stability, and achieve patient satisfaction (24). Over time, the diagnosis and surgical planning for dentofacial deformities have evolved from 2D methods like orthopantomography and plaster models to 3D virtual planning using CT, CBCT, intraoral scans, and facial scans, which allows for more precise, efficient, and patient-friendly surgery (25–27).

While technological advancements have increased predictability, efficacy, and simplicity in the surgical phase, there remains a lack of unified treatment protocols across the entire care pathway, considering the various professionals involved and the clinical and instrumental investigations required (27–31). Thus, the necessity to assess and develop tools to meet the needs of typical orthognathic patients and identify their unmet needs. The Blueprint “Personas” approach, formulated by the “Blueprint on Digital Transformation in Health and Care in an Ageing Society”, offers an intuitive process for identifying specific patient subsets' unmet needs (World Health Organization 2019) (16–19, 32). This study aims to identify key digital solutions and user scenarios for individuals with a dentofacial deformity profile, adapting the “Blueprint” user-centered design methodology. As part of the DHEAL-COM project, a phone survey (Table 1) was conducted with 135 patients treated at the Maxillofacial Unit of Federico II University Hospital from 2017 to 2023, to analyze their demographic, clinical, and social characteristics. An interdisciplinary Focus Group developed the theoretical “Dentofacial deformity persona” (Mariangela). Analyzing data from 135 patients and identifying frequently occurring characteristics (gender, age, education, comorbidities).

A number of unmet needs were highlighted for these patients (Table 2). These include the need for psychological support throughout the pre- and post-operative pathway. As highlighted by Dons et al. (33) up to 13% of BDDs have disorders related to self-image dissipation requiring targeted behavioral treatment, so-called Body Dysmorphic Disorder (BDD).

Body Dysmorphic Disorder (BDD) is a mental health condition characterized by an obsessive focus on one or more perceived flaws in physical appearance, which are either minor or not observable to others. Individuals with BDD can spend hours a day thinking about their perceived defects, leading to significant distress and impairments in daily functioning. In DFD patients this disorder is definitely more highlighted (33). Furthermore, Madhan et al. (34) showed that patients with DFD have a higher prevalence of Temporo Mandibular Disorders TMD (14 to 97%) and oro-facial pain (33%) compared to those without. This condition aggravates the patient's symptom picture with pain and chewing disorders that need proper framing as early as preoperatively (34). Also fundamental for these patients is a speech therapist support: as described by Farronato et al. (35) there are significant correlations between malocclusion and dyslalia. The presence of Class III occlusion, diastema, increase in overjet, presence of open and deep bite, asymmetry have high tendency to be associated with speech disorders such as dyslalia. Another unmet need pertains to the need for a common platform for dialogue with the various professionals on the multidisciplinary team. The Nutritional management for these patients should also not be neglected for two main reasons: firstly, since the surgery directly affects the oral apparatus and chewing mechanisms, controlled nutrition, and the use of liquid or semi-liquid diets are essential, especially in the initial weeks post-surgery (9). Secondly, considering caloric intake and the distribution of macro- and micro-nutrients is vital; patients require a complete, possibly high-calorie diet for proper healing of bone fractures (36, 37). Last but not least, as firstly demonstrated by Miyao et al. malocclusion, specifically overjet, was associated with the severity of OSAS in non-obese patients, suggesting that malocclusion may play an important role in the development of sleep apnea/hypopnea (38).

The blue print methods enabled easy and accurate identification of ICT needed to satisfy unmet needs. Five key technological areas were pinpointed to address these patients' unmet needs: 1.

Health information exchange;

Based on these insights, a common care pathway incorporating key digital solutions was defined. This pathway (Figures 1, 2) was structured around pre- and postoperative management: in the preoperative phase, a set of clinical and instrumental investigations and necessary specialist outpatient visits were standardized. The key points are: appropriate preoperative imaging (CT cone beam, intraoral scans, cephalometry), proper framing of airway disorders with rhinomanometry and polysomnography, nutritional and speech evaluation for setting an adequate diet and psychological support.

The postoperative pathway standardized the order of specialist outpatient visits, enabling patient support throughout the healing process and their acceptance of their new image, both through in-person visits and remotely via the platform (key digital solution). The pathway includes a total of 2 in-person outpatient visits aimed at giving an initial framing of dentoskeletal dysmorphia and defining the correct diagnostic-therapeutic pathway and includes 4 platform meetings (telemedicine). The latter have the function of reducing in-person visits and improving interdisciplinary communication between the specialist figures involved in the management of the pathology. They also have the benefit, by avoiding excessive physical travel, of improving patient compliance with treatment, thus being able to bring patients from distant geographic realities closer to the proposed therapeutic pathway and thus favoring the phenomenon of “health migration”.

Certainly, our work is a preliminary study and has limitations, first the lack of validation of the realized pathway; our future perspective is to put the pathway into practice and validate it through an implementation protocol. Other limitations regard: technology literacy among the patients and healthcare providers; issues related to multidisciplinary coordination. Although the study has these limitations, the most important impact concerns health equity, considering that by exploiting these digital solutions even patients in remote and patients by underserved areas can benefit from these services.

This study highlights that the Blueprint methodology proves instrumental in pinpointing specific characteristics and unmet needs of various patient groups. In fact, this approach is simply based on creating a digital twin of a specific category of patients, condensing all the characteristics and needs of the different patients of that category, in order to search for solutions to satisfy these unmet needs more quickly. By creating a detailed patient Persona, by using the Blueprint methodology, unmet needs of DFD patients have been identified, such as psychological support, nutritional guidance, oral hygiene advice. The critical gaps in the diagnostic-therapeutic pathway for patients with dentofacial deformities underscores the potential of digital solutions in addressing these unmet needs. The proposed digital tools, including video tutorials, online courses, smartphone notifications, social media channels, and multidisciplinary platforms, provide a promising avenue to enhance patient engagement, streamline care delivery, and improve overall treatment outcomes. Future research should focus on validating these solutions in clinical settings to ensure their feasibility and effectiveness in addressing the unique demands of DFD patients. Once the real-world validation of the model and of the questionnaire has been obtained, this methodology could be used as a model for others complex health condition requiring multidisciplinary care.