Orthodontic and orthognathic surgical treatments are provided to patients who suffer from dentofacial deformities. These deformities not only result in malocclusions but also affect the facial profile. Therefore, surgeons and orthodontists should simultaneously consider both the facial profile and the bite occlusion to achieve the ideal correction. They also must determine the best solution for each individual patient (Fig. 1.1). Although the restoration of bite occlusion should be the fundamental basis of orthognathic surgery and orthodontic treatment, there is also a current focus on the patient’s facial profile. Regarding the orthognathic profile, dentofacial deformity could be categorized into concave and convex profile. Then, its growth pattern could be subcategorized into anterior and posterior divergent profile. Based on the individual patient’s profile and occlusal status, the best option for the orthognathic surgery should be determined.

The surgery-first approach (SFA) or the surgery-first orthognathic approach (SFOA) is defined as orthognathic surgery without the presurgical orthodontic treatment that was, traditionally, a prerequisite to orthognathic surgery. Therefore, SFA is a concept that not only challenges the status quo but also is a new paradigm in craniofacial surgery. Traditionally, to overcome postoperative occlusal instability, presurgical orthodontic treatment was deemed to be essential for achieving successful, long-term orthognathic procedure outcomes [1]. However, since the original cause of the dentofacial deformity is a skeletal discrepancy, orthognathic surgery should be used for correction. I agree with this expression by Dr. YuRay Chen about the concept of SFA. Thus, why would the skeletal discrepancy, the fundamental etiology of the dentofacial deformity, not be corrected first? Such an approach seems rational and logical. However, a question remains regarding how to overcome the postoperative occlusal instability. Generally, there are three approaches to solving this obstacle.

First, South Korean groups often make use of the fact that the SFA direction is the same as the postsurgical orthodontic treatment [2]. Second, some Japanese groups depend on the active use of pre- and postoperative tooth management, including cusp grinding and mini screw use [3]. Third, Taiwanese groups have recommended SFA, based on the regional accelerated phenomenon (RAP), using corticotomies [4]. It seems like that each group developed the surgery first approach with a little different concept.

Although there is some controversy regarding who first suggested the SFA concept, a literature search for the original paper suggests that South Korean authors wrote most of the early papers. In 2002, Korean orthodontists (the “Smile Again Orthodontic Group”) published the SFA in a “The Korean journal of clinical orthodontics”, calling the procedure “functional orthognathic surgery” (Fig. 1.2). In this article, the authors clearly addressed and described SFA, without presurgical orthodontic treatment; this would be the fundamental concept behind modern SFA from my understanding.

The authors of the 2002 study insisted that SFOA, without presurgical orthodontic treatment, was possible, based on the novel, mock dental surgery that included mimicking the presurgical orthodontic treatment process for separating the teeth. The article already showed several very successful surgical clinical outcomes using the SFA concept. Korean orthodontic groups, such as the Smile Again Orthodontic Center, started using SFA in 2001, and our institution, cooperating with the Smile Again Orthodontic Group, started using SFA in 2007. Our group has suggested SFA concepts and demonstrated clinical SFA outcomes, based on feasibility testing with mock SFA dental surgeries, in multiple publications.

This balance of this chapter will address the current SFA concept, discuss the controversial issues found in the current literature, and describe our 15 years of clinical experience with SFA.

1.1 Definition and Evolution of SFA

SFA is an orthognathic approach that consists of orthognathic surgery and postsurgical orthodontic treatment, in the absence of presurgical orthodontic treatment [5]. This procedure is regarded as a paradigm shift from the traditional orthognathic approach. In the past, some orthognathic surgeries were performed without proper presurgical orthodontic treatment (Fig. 1.3). This occurred before the establishment of the traditional protocol that involves 12–18 months of presurgical orthodontic treatment, followed by the orthognathic surgery and 6–12 months of postsurgical orthodontic treatment [6]. However, this approach cannot be regarded as SFA in keeping with the modern SFA concept. Despite some controversies, the first paper describing SFA was published, in 2002, in the Korean Journal of Clinical Orthodontics (1(1): 32–39, 2002). This article addressed the modern concept of SFA, referred to as “functional orthognathic surgery.” The procedure was described as consisting of orthognathic surgery followed by postsurgical orthodontic treatment, without any presurgical orthodontic treatment; the procedure was based on novel laboratory work. When it comes to our concept of SFA, the laboratory work of ours does not mean the simple estimation of the occlusion with presurgical orthodontics, but includes the novel process where the each teeth, separated from the dental model, were simulated. The clinical cases included in the article involved separation of the teeth, using a dental model to simulate the immediate postsurgical occlusal status, without presurgical orthodontic treatment. The model simulation of the teeth allows the surgeon or orthodontist to recreate the surgery-first status and skip the traditional presurgical orthodontic treatment. This approach remains the fundamental basis of clinical SFA applications in our practice.