Surgery first approach in orthognathic surgery: Orthodontic considerations

Introduction

Orthognathic surgical procedures are effectively performed using an interdisciplinary approach to correct skeletal problems or dentofacial deformities that are difficult to treat with orthodontic camouflage therapy. Orthognathic surgical procedures traditionally involve a pre-surgical phase of orthodontics followed by a surgical phase and post-surgical orthodontics. Historically, the evolution of orthognathic surgery involved surgery first, followed by orthodontics. However, due to the inability to achieve optimal outcomes in severely compensated malocclusion, it was necessary to decompensate malocclusion to its fullest expression during the pre-surgical phase and finish the occlusion during the post-surgical phase of treatment orthodontically.

Goals of pre-surgical orthodontics

The goals of pre-surgical orthodontics are as follows but are not limited to

  • •

    Eliminate occlusal interferences

  • •

    Align dental arch forms

  • •

    Coordination of the dental arches, in transverse dimensions, specially inter-canine widths

  • •

    Decompensate dental inclinations in labiolingual direction

  • •

    Level the curve of Spee

The joint interdisciplinary approach often necessitated a long period of orthodontic treatment, which often temporarily worsened the profile before surgery was performed. Long pre-surgical orthodontic phase and living with a temporary worsened profile were unacceptable to many adult patients seeking quick solutions to improve their profile, mainly for social reasons.

To overcome these issues and hasten the settlement of occlusion, Hong and Lee (1999) introduced the concept of undertaking orthognathic surgery with no or minimal orthodontics. The phrase ‘Surgery First’ was proposed by Nagasaka et al. and was popularised by Liou and Huang, which is appropriately termed the Surgery First Orthognathic Approach (SFOA) or Surgery First Approach (SFA). With this therapeutic approach, patients needing skeletal correction through orthognathic surgery (OGS) undergo initial surgical intervention to rectify the underlying skeletal irregularity. Subsequently, dental corrections are accomplished by utilising a fixed appliance and finishing with the goals of occlusion to enhance the stability of surgical outcomes. These approaches differed from the conventional or orthodox approach, wherein the dental malocclusion problems are first addressed or ‘decompensated’ using a fixed appliance, followed by orthognathic surgery. SFOA offers several advantages over the traditional approach to OGS.

Advantages of SFOA

  • 1.

    The patient’s chief complaints related to dentofacial deformity are addressed at the commencement of the treatment.

  • 2.

    Eliminates pre-surgical orthodontic treatment (PrSOT), which is the most time-consuming stage, ranging from 7 to 47 months.

  • 3.

    Eliminates temporary worsening in profile during pre-surgical phase. , ,

  • 4.

    The duration of total treatment can be reduced to 12 or 18 months, with a nearly 50% reduction due to rapid tooth movements associated with the regional accelerated phenomenon (RAP), the environment being available through enhanced inflammation consequent to surgical trauma.

  • 5.

    Patient acceptance is high.

  • 6.

    Masticatory muscle weakness is avoided.

  • 7.

    Fast progress in many functions like swallowing and speech after surgery. ,

  • 8.

    Surgical relapse can be managed well.

The SFOA is indicated in limited and selected cases of skeletal deformities.

Indications for SFOA ,

  • 1.

    Individuals with facial deformities requiring immediate interventions to enhance their profile.

  • 2.

    Skeletal malocclusions requiring minimal pre-surgical orthodontic alignment and decompensation, with mild to moderate crowding.

  • 3.

    Malocclusions with minimal transverse discrepancies, thus permitting adequate coordination of the maxillary and mandibular arches following surgery.

  • 4.

    Distinct soft tissue imbalance, particularly in patients with class III malocclusion.

  • 5.

    Patients with moderate to severe class II skeletal malocclusions.

  • 6.

    Facial asymmetries with minimal occlusal interference when surgery is planned.

  • 7.

    Cleft lip and palate patients with aligned arches.

  • 8.

    SFOA can be considered in skeletal class II/III deformities, apertognathia and class I with bidental proclination and facial asymmetry when

    • a.

      Anterior teeth are aligned, or crowding is minimal.

    • b.

      When the curve of Spee is mild or flat.

    • c.

      When the incisor inclination is mildly increased, retroclined or upright.

Fig. 80.1.i shows an adult with skeletal class III malocclusion with well-aligned upper and lower arches. Such a clinical situation is a good indication for SFOA.

Figure 80.1.i

Pre-treatment profile and occlusion of an adult with severe skeletal and dental class III malocclusion. Note well-aligned upper and lower arches. This is a good case for surgery first approach.

Figure 80.1.ii

Pre-treatment cephalogram of an adult with severe skeletal and dental class III malocclusion. Both jaws are affected. While the maxillary incisors have a significant proclination, the mandibular incisors are nearly upright on the base and do not require substantial decompensation. The third molars are erupted and in occlusion. The absence of impactions of third molars makes this case favourable for surgery first approach.

Figure 80.1.iii

Post-surgery profile shows instant improvement in the facial profile. Some oedema is sustained, which will wean off slowly in the next 10–15 days. The post-surgery cephalogram corroborates soft tissue profile changes. The maxilla received Le Fort 1 and mandible BSSO and reduction genioplasty. Rigid fixation was provided, which is evident in the X-rays. Note instant improvement in soft tissue, skeletal profile and overjet. The case is ready for detailing the occlusion with a short course of fixed appliance therapy in a non-extraction approach since arches are aligned and nearly normal on their respective bases.

The surgery was done by the maxillofacial surgeon Prof. Dr. J Naveen Kumar and team.

Figure 80.1.iv

(A) Pre-treatment occlusion (B) during fixed appliance therapy and (C) occlusion at the competition of the orthodontic treatment. Note a class I molar and canine relations, normal overjet and overbite well aligned and coordinated dental arches up to third molars. The adult patient has benefitted much from the surgery first approach (SFA) without going through a phase of pre-surgical orthodontics. The total treatment time was 14 months. The wire sequence was upper and lower 016 nickel titanium (NiTi), followed by 0.016 × 0.022 in. NiTi, 0.016 × 0.022 in. SS, 0.017 × 0.025 in. NiTi and SS, 0.019 × 0.025 in. NiTi and SS, followed by finishing wires.

Figure 80.1.v

Post debond/cephalogram of an adult with severe skeletal and dental class III malocclusion. Note improvement in skeletal profile and overjet. The buccal occlusion and the axial and labiolingual inclinations of the teeth are well settled.

Figure 80.1.vi

Post-surgery profile at one year followup shows stable improvement in facial profile and smile.

Figure 80.1.vii

Occlusion at 1 year of follow-up. Class I molar and canine relations, normal overjet and overbite, well aligned and coordinated dental arches up to third molars are maintained well.

Contraindications and limitations of SFOA

SFOA is not suitable for the whole spectrum of dentofacial deformities. Only selected patients can fulfil the criteria for SFOA since the quantum of skeletal correction is restricted without pre-surgical orthodontics.

These are the cases with:

  • 1.

    Severe vertical discrepancy

  • 2.

    Severe crowding

  • 3.

    Severe axial inclinations of anterior teeth

Limitations

  • 1.

    Lack of transverse arch coordination that could lead to interferences after orthognathic surgery.

  • 2.

    Uncertainty in post-surgical occlusion could lead to unstable post-surgical occlusion and, therefore, prone to relapse.

  • 3.

    Only trained and proficient orthognathic teams can perform this approach. The team must discuss continuously and constantly with an open mind.

  • 4.

    This transitional occlusion must be corrected to a stable occlusion with skill and experience.

Steps in SFOA

After a case selection and joint discussions with the team and treating orthodontist, intended transitional malocclusion (ITM) is visualised. ITM is the phrase used to predict the occlusion which will be obtained following the surgery. The surgical splint is constructed using this predicted occlusion and thus will aid the surgeon in attaining pre-planned occlusion during the surgery and rigid fixation of the osteotomised segments.

A tripoding or a minimum of a three-point occlusal contacts is desired following surgery. The decompensation of the incisors would not have been accomplished, and hence, the axial inclination of the incisors cannot be used as the beginning point of treatment. The molar’s position can be the preliminary or initial step to plan the ITM. It is critical to visualise the transitory occlusion, ITM and must be thoughtfully planned for its bearing on the stability of the surgical outcome.

The nature and severity of pre-treatment malocclusion would influence the ITM. In mild to moderate cases, a tripoding is the minimum requirement. If the upper incisors are proclined and the lower incisors are retroclined, the occlusion should have a large overjet to enable retraction of the upper incisors and uprighting of the lower incisors. The transverse relationship correction would be the biggest challenge, and the ensuing transverse problem should ideally not be more than one-half of the width of the maxillary molar buccal cusp. In the vertical dimension, for the low angle case, there should be provision for supraeruption of the molars, and for the high angle patient, there should be a plan for the management of an open bite by extruding the incisors. The buccal segment of teeth should be in occlusion with minimal possibility for supraeruption. Fig. 80.2 depicts conventional steps employed in SFOA.

Figure 80.2

Steps in surgery first approach.

Minimal orthodontics

SFOA is evolving with clinical experience in handling a variety of cases and research. The five schools of thought related to SFOA are based in Japan, Korea, Taiwan, Spain and the USA. They primarily differ in the protocols. Almost all protocols bond the patients with fixed appliances 24–48 h prior to surgery, and the initial arch wires are placed within 30 days after surgery.

Occlusal interferences are the crucial disadvantage of SFOA, but they can be managed with modified SFOA. In cases where a temporary occlusion is not feasible, Uribe et al. suggested minimal tooth movement to eliminate potential interferences. This approach would increase the stability of the occlusion following surgery. This protocol is referred to as minimal orthodontics SFOA. The Maximum Efficiency Minimal Orthodontics (MEMO) strategy consisted of 2–4 months of minimum pre-surgical orthodontics, minimum levelling, decompensation and arch coordination to achieve a maximal occlusion. This approach would reduce the complexity of interferences expected following surgery. Any suspicion of increased levels of interference warrants the need for MEMO or minimal orthodontics SFA.

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May 10, 2026 | Posted by in Orthodontics | 0 comments

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