Surgery-first Orthognathic Approach Research Articles

Surgery-first in interdisciplinary class II cases.

To present an interdisciplinary case treated with a surgery-first orthognathic approach, followed by orthodontic and prosthodontic treatment. After an accurate pre-operative virtual planning, a young patient with skeletal class II, retrognathia, and an anterior open bite was treated with bimaxillary orthognathic surgery without pre-surgical orthodontic decompensation. Orthodontic treatment was carried out post-operatively. The treatment was completed with a prosthodontic phase to improve the final esthetic outcome of the smile. A surgery-first approach allowed to achieve esthetic and functional results in a reduced treatment duration that remained stable over the course of 1 year. The outcomes were consistent with prior research in terms of advantages brought by following an accurately planned surgery-first protocol. Nevertheless, longer-term follow-up was required to evaluate the treatment stability. An accurately planned surgery-first approach significantly helped in shortening the duration of the treatment, while providing a stable, functional, and esthetic solution to the patient's problems.

Application of Surgery-First Approach in Treating Skeletal Dentofacial Asymmetry with Orthognathic Surgery.

Skeletal dentofacial asymmetry decreases patient's attractiveness by deteriorating symmetry of facial appearance which is of great significance to individuals. Surgery-first orthognathic approach manifests its advantages of shortening treatment time and improving patient's quality of life. However, current literature on surgery-first approach mainly focuses on treating prognathism, overlooking its efficacy in improving facial symmetry of skeletal dentofacial asymmetry patients. This study aimed to assess SFA's efficacy in improving facial appearance by analyzing morphological features of asymmetric bone and facial soft tissue in a three-dimensional manner. Thirty-four patients who received orthognathic surgery in a surgery-first fashion were included. Based on three-dimensional CT reconstruction, bilateral preoperative morphological features and postoperative symmetry of hard tissue were compared respectively. Efficacy of facial soft tissue symmetry restoration was evaluated using root mean square deviation (RMSD). Asymmetric features mainly located in menton, mandibular body length, angulation between ramus and midsagittal plane (MSP), distance between gonion and MSP and so on, which were significantly restored after the whole treatment. RMSD of facial soft tissue surface were significantly declined after the treatment and prognathism was corrected simultaneously if existed. Surgery-first orthognathic approach is proved to be capable of treating skeletal dentofacial asymmetry effectively and efficiently.

Three-Dimensional Evaluation of Skeletal Stability following Surgery-First Orthognathic Approach: Validation of a Simple and Effective Method

Background The three-dimensional (3D) evaluation of skeletal stability after orthognathic surgery is a time-consuming and complex procedure. The complexity increases further when evaluating the surgery-first orthognathic approach (SFOA). Herein, we propose and validate a simple time-saving method of 3D analysis using a single software, demonstrating high accuracy and repeatability. Methods This retrospective cohort study included 12 patients with skeletal class 3 malocclusion who underwent bimaxillary surgery without any presurgical orthodontics. Computed tomography (CT)/cone-beam CT images of each patient were obtained at three different time points (preoperation [T0], immediately postoperation [T1], and 1 year after surgery [T2]) and reconstructed into 3D images. After automatic surface-based alignment of the three models based on the anterior cranial base, five easily located anatomical landmarks were defined to each model. A set of angular and linear measurements were automatically calculated and used to define the amount of movement (T1-T0) and the amount of relapse (T2-T1). To evaluate the reproducibility, two independent observers processed all the cases, One of them repeated the steps after 2 weeks to assess intraobserver variability. Intraclass correlation coefficients (ICCs) were calculated at a 95% confidence interval. Time required for evaluating each case was recorded. Results Both the intra- and interobserver variability showed high ICC values (more than 0.95) with low measurement variations (mean linear variations: 0.18 mm; mean angular variations: 0.25 degree). Time needed for the evaluation process ranged from 3 to 5 minutes. Conclusion This approach is time-saving, semiautomatic, and easy to learn and can be used to effectively evaluate stability after SFOA.

Surgery-First Orthognathic Approach for Correction of Dentofacial Deformity in Unilateral Cleft Lip and Palate.

Although several studies have reported the advantages of the surgery-first approach for orthognathic correction of class III deformity, there is no report of the success of this approach for patients with cleft lip and palate. Therefore, the purpose of this study was to evaluate the stability and outcome of bimaxillary surgery for cleft-related dentofacial deformity using a surgery-first approach. Forty-one patients with unilateral cleft lip and palate who consecutively underwent Le Fort I and bilateral sagittal split osteotomies for skeletal class III deformity were included. Cone-beam computed tomographic scans before surgery, 1 week after surgery, and after orthodontic treatment were used to measure the surgical and postsurgical changes in jaw position by landmarks, and outcomes of jaw protrusion and relation, incisor angle and occlusion, and menton deviation after treatment. Self-report questionnaires regarding satisfaction with overall appearance of the face and seven facial regions were administered after treatment. A clinically insignificant relapse was found in the maxilla (<1 mm) and mandible (<2 mm). There was a significant improvement in the jaw protrusion and relation, incisor angle and occlusion, and menton deviation. Responses from the self-report questionnaires completed after treatment indicated that patient satisfaction was high. These findings demonstrate surgical-orthodontic treatment with a surgery-first approach can successfully improve cleft-related dentofacial deformity in patients with unilateral cleft lip and palate. Therapeutic, IV.

Advances in the surgery-first orthognathic approach for the treatment of patients with malocclusion

Advances in the surgery-first orthognathic approach for the treatment of patients with malocclusion

An integrated 3D-driven protocol for surgery first orthognathic approach (SFOA) using virtual surgical planning (VSP)

Appropriate case selection, meticulous planning, and execution are essential to the success of surgery-first orthognathic approach (SFOA). Some of the drawbacks associated with the traditional method of SFOA planning include; inaccurate bite registrations, along with tedious laboratory procedures to generate bite-wafer for transitional occlusion. These limitations can be addressed with the rise of contemporary new-age digital orthodontics encompassing a wide spectrum of technologies, such as, intra-oral scanners, prediction and designing software, 3D printers, and artificial intelligence (AI) guided navigation systems. These technologies have shown immense promise and have been extensively used in surgical planning in recent times. It is the need of the hour to generate evidence-based outcomes from high quality randomised control trials (RCTs) and standard core outcomes (COS) for digital planning in SFOA to rise higher in the evidence pyramid ladder. The current paper elaborates, in detail, on the various 3D technologies available and their modes of implementation for SFOA cases.

Clinical application of Clear Aligner Treatment (CAT) in the Surgery-First Orthognathic Approach (SFOA)

Recent digital technological advancements in orthodontics have streamlined the surgery-first orthognathic approach (SFOA). Currently, it is established that simulation of complex surgical movements can be done digitally. However, there is lack of clarity on clinical protocols employed in Clear Aligner Treatment (CAT) for the management of Surgery-First Orthognathic Approach (SFOA). The primary objective of this article is to provide an, in-depth, answer to this question. This is a first-of-its-kind article that effectively utilizes clinical scenarios and case reports to meticulously describe the requirements of presurgical orthodontics, protocols during surgery, and post-surgery commencement of aligner-orthodontics in three dimensions (transverse,vertical and sagittal), along with clinical tips, dos, and don'ts.

Insights into concepts, protocols, and evidence of surgery-first orthognathic approach-The journey so far

The aim of this narrative review was to comprehensively describe the surgery-first orthognathic approach (SFOA) or the surgery-first approach (SFA) in terms of the concept, procedure selection and evidence available to date. Comparisons with the conventional orthognathic surgery approach (COSA) are also made. In the light of newer advances in technology, including but not limited, to augmented reality - virtual treatment objective setup, 3D imaging, and computer-aided design and manufacturing (CAD/CAM), the “one patient two problems concept” needs to be thoroughly understood to further enhance both patients’ quality of life and practitioners’ clinical skills. Undoubtedly, gathering higher levels of evidence from future randomized control trials (RCTs) and developing standard core outcomes (COS) on SFOA are the need of the hour.

Evaluation of alveolar bone changes around mandibular incisors during surgical orthodontic treatment of patients with mandibular prognathism: Surgery-first approach vs conventional orthognathic surgery

This retrospective study aimed to investigate the alveolar bone changes around mandibular incisors in patients with skeletal Class III malocclusion treated with surgery-first orthognathic approach (SFA) and conventional orthognathic surgery (COS) using cone-beam computed tomography scans. Sixty-four patients were divided into 2 groups according to the inclusion of presurgical orthodontic treatment; the SFA group included 32 patients treated without presurgical orthodontic treatment, and the COS group included 32 patients treated with presurgical orthodontic treatment. Cone-beam computed tomography scans were obtained before treatment, after presurgical orthodontic treatment, and after treatment for the COS group and were obtained before and after treatment for the SFA group. The measurements of vertical alveolar bone height and horizontal bone thickness at 4 levels and the alveolar bone area surrounding the mandibular incisors were compared according to the treatment progress and groups. The vertical bone levels and horizontal bone thickness of the labial and lingual sides and the area of the alveolar bone around the mandibular incisors were reduced after treatment in both SFA and COS groups. Vertical bone loss was more prominent than horizontal bone loss after treatment in both groups, and alveolar bone loss was greater on the lingual side than on the labial side. There were no significant differences in alveolar bone changes around the mandibular incisor between the SFA and COS groups. However, the alveolar bone was reduced more in the COS group than in the SFA group. The results indicate that SFA and COS may trigger degeneration of the alveolar bone around the mandibular incisors after treatment in patients with mandibular prognathism. Careful consideration is needed to avoid iatrogenic degeneration of the periodontal support around the incisors, particularly during presurgical orthodontic treatment.

Advanced Digital 3D Technology in the Combined Surgery-First Orthognathic and Clear Aligner Orthodontic Therapy for Dentofacial Deformity Treatment

Orthognathic surgery and orthodontic treatment are required for patients with dentofacial deformities to obtain an ideal facial esthetic with good functioning. Recently, characterized by the surgery-first approach, an integrated orthodontic–surgical treatment has been introduced as an emerging solution to dentofacial deformity treatment. The surgery-first approach is regarded to have less treatment time and quicker enhancement of a facial profile than the conventional orthodontic–surgical treatment. Moreover, the recent advances in computing and imaging have allowed the adoption of 3-dimensional (3D) virtual planning protocols in orthognathic surgery as well as digital orthodontic treatment, which enables a paradigm shift when realizing virtual planning properly. These techniques then allow the surgeon and orthodontist to collaborate, plan, and simulate the dentofacial deformity treatment before performing the whole procedure. Along this line, in this research article, we present an integrated treatment method for the realization of an effective deformity treatment. Specifically, we implemented the integrated 3D technique by combining it with the surgery-first orthognathic approach (SFOA) as a novel treatment method for the patients. The outcomes from the combined treatments of the patients with dentofacial deformity, in practice, have demonstrated that our proposed 3D technique in orthognathics and orthodontics using clear aligner therapy (e.g., Invisalign) can enhance the satisfactory level of the patient since the start of treatment then improve their quality of life. As a result, the combined techniques realize the novel integrated treatment method using 3D technology with the use of 3D imaging and modeling as a promising development trend of dentistry, which fits into the context of Dentistry 4.0 as a key enabler to the concept of sustainable dentistry development.

Surgery-first orthognathic approach for the correction of facial asymmetry

We aimed to compare the reliability of the surgery-first approach and the traditional orthodontic-first approach for the correction of facial asymmetry based on the new classification of facial asymmetry.Patients with facial asymmetry who underwent orthognathic surgery between January 2016 and January 2019 were included. Cephalometric changes and relapse ratios were analyzed 12 months before and after surgery. Patients were divided into horizontal and vertical asymmetry groups based on the asymmetry vector, and subgroup analysis was conducted.The surgery-first approach without presurgical orthodontic treatment and the orthodontic-first approach showed a similar degree of asymmetry correction and skeletal stability. The relapse ratios of the maxilla height in the surgery-first and orthodontic-first groups were 0.25 ± 0.21 and 0.27 ± 0.25, respectively (p = 0.63), the relapse ratios of the maxilla width were 0.31 ± 0.32 and 0.21 ± 0.2, respectively (p = 0.14), the mandibular height relapse ratios were 0.34 ± 0.58 and 0.29 ± 0.36, respectively (p = 0.69), and the mandibular width relapse ratios were 0.12 ± 0.22 and 0.26 ± 0.31, respectively (p = 0.058). The treatment period of the surgery-first group (18.5 ± 5.3 months) was significantly shorter than that of the orthodontic-first group (22.9 ± 7.5 months, p = 0.024). Among the surgery-first group, patients with vertical asymmetry (15.0 ± 3.2 months) had a shorter treatment than those with horizontal asymmetry (21.6 ± 6.8 months, p = 0.006).Although contesting traditional standards is always challenging, the surgery-first orthognathic approach may lead to a new era in traditional orthognathic approaches. This new classification of facial asymmetry could be useful and practical when treating patients with facial asymmetry regardless of the etiology.

Current concept of the surgery-first orthognathic approach.

Traditional orthognathic surgery has long been performed after presurgical orthodontic treatment. Despite some concerns, the surgery-first orthognathic approach (SFOA) or surgery-first approach (SFA) without presurgical orthodontic treatment has gradually gained popularity. In recent years, several articles dealing with the concepts of the SFA have been published worldwide. However, the SFA has not yet been standardized, and many surgeons use slightly different protocols and concepts. This review article discusses the beginning and evolution of the SFA and its current concepts, including some opinions based on the authors’ clinical experiences over the last 15 years. According to recent investigations, the SFA could be applied effectively in several situations including class III malocclusion, class II malocclusion, and facial asymmetry. However, debate on the SFA continues and many issues remain to be resolved. This review article addresses the current issues regarding the SFOA, including its advantages and disadvantages, as well as its indications and contraindications. The authors summarize various aspects of the SFA and expect that this review article will help surgeons and orthodontists better understand the current status of the SFA.

Reliability of Predicting the Final Treatment Outcome in Surgery First Orthognathic Approach (SFOA)

Reliability of Predicting the Final Treatment Outcome in Surgery First Orthognathic Approach (SFOA)

An overview of surgery-first orthognathic approach: History, indications and limitations, protocols, and dentoskeletal stability

The most common orthognathic surgery approach consists of three steps: presurgical orthodontic treatment, surgery, and postsurgical orthodontic treatment. Despite its advantages, this technique has some disadvantages, too, including a long treatment period, problems in mastication and articulation, temporary worsening of the patient's appearance, and psychological problems for the patient. The introduction of the surgery-first orthognathic approach has been an attempt to overcome these problems. In this article, we wish to provide a comprehensive overview on this approach. In this approach, which consists of surgery without orthodontic preparation and a short period of orthodontic treatment after it, the overall duration of treatment decreases and the patient's appearance improves. The skeletal anchorage, placed at the time of surgery, can be used to facilitate tooth movements after surgery. Despite the advantages of this technique, it is associated with some limitations; in particular, occlusion cannot have a guiding role during surgery. Therefore, correct diagnosis, prediction of the outcomes, and simulating correction with the model setup are of crucial importance. The surgeon's knowledge and expertise have a significant role in this respect.

Speedy orthodontics - Surgery first orthognathic approach

Skeletal malocclusions are the result of variation in the relationship between skeletal, dental and overlying soft tissues. Management of these malocclusions in adults requires orthognathic surgery in combination with orthodontics. Until 1960s, surgeons and orthodontists worked independently to correct dentofacial deformities. Thereafter, the conventional approach for correction of severe dentofacial anomalies was introduced which consisted of three stages (presurgical, surgical, postsurgical). As treatment with conventional orthognathic surgery involves a prolonged time period, surgery first orthognathic approach (SFOA) was introduced in which orthognathic surgery is done first followed by orthodontic treatment for alignment of the teeth and settle the occlusion. By performing surgery first approach, Regional Acceleratory Phenomenon (RAP) is initiated which is an important factor in reduction of treatment duration in SFOA. This article intends to provide an overview of the history, indications, advantages, disadvantages, stability of SFOA. Keywords: Skeletal malocclusions, Conventional orthognathic surgery, Surgery first orthognathic approach, Regional acceleratory phenomenon.

Surgery-first orthognathic approach vs conventional orthognathic approach: A systematic review of systematic reviews

Surgery-first approach (SFA) has been introduced as an alternative for conventional orthognathic approach (COA) in the treatment of patients with dentoskeletal deformities. This review aimed to evaluate skeletal stability, treatment time, surgical complications, and quality of life in SFA and COA. Six databases were accessed up to May 2020 to obtain all systematic reviews (SRs). After title and abstract reading, data extraction was performed from eligible SRs. The methodological quality was calculated for the included SRs using the last version of A Measurement Tool to Assess Systematic Review (AMSTAR-2). Ten SRs were included in this review. A good stability of the jaws was assessed both with SFA and COA by most of low- or critically low-quality SRs. Less treatment time was reported for SFA than COA with a moderate quality level. Slightly higher complications rate was recorded with SFA than COA by SRs with low or moderate quality. A better quality of life with SFA than COA was reported by moderate- or low-quality SRs. SFA may represent a reasonable alternative to COA. However, for the heterogeneity of the included SRs, well-designed studies with a long term follow-up are needed to clarify the findings of this analysis.

Effect of surgery-first orthognathic approach on oral health-related quality of life.

To systematically evaluate the effect of the surgery-first approach (SFA) on oral health-related quality of life (OHRQoL) in patients with dentofacial deformities. An electronic database search and hand search of selected journals and references were carried out. Studies investigating the OHRQoL of patients receiving SFA with or without a control group were included. The risk of bias was assessed by the Cochrane risk of bias tool in randomized clinical trials (RCTs) and the Newcastle-Ottawa Scale in non-RCTs. A total of seven articles met the eligible criteria and were included, of which six were cohort studies and one was an RCT, and six assessed the OHRQoL of the SFA with conventional orthodontic-surgical treatment (COST) as a control and one without. A total of 214 patients were examined, with sample sizes in studies ranging from 9 to 50. A total of 3 articles successfully measured the OHRQoL both before and after treatment in both the SFA and conventional orthodontic-surgical treatment groups. A total of six cohort studies were classified as low to moderate risk of bias, and the RCT was classified as high. The SFA could improve the OHRQoL of patients with dentofacial deformities similar to conventional orthodontic-surgical treatment at the end of complete treatment. In addition, it increases OHRQoL immediately at the beginning of treatment without a deterioration.

Evaluation of Airway Dimensions Following Mandibular Setback with Surgery-First Orthognathic Versus Conventional Orthognathic Approach.

To evaluate changes in airway dimensions following mandibular setback with conventional orthognathic approach (COA) and surgery-first orthognathic approach (SFOA). Treatment records of 20 patients who underwent mandibular setback with SFOA/COA were divided into two groups (COA and SFOA, ten patients in each group). Acoustic pharyngometry values were obtained at T0 (01week prior to surgery), T1 (01-month post-surgery) and T2 (01-year post-surgery). Percentage change in mean volume and area was obtained at T1 (T1-T0) to evaluate airway changes and at T2 (T2-T1) to compare relapse of airway changes in both groups. Changes in airway per mm setback at T1 (T1-T0) and T2 (T2-T1) were also obtained in both groups. For both parameters, SFOA showed greater reduction at T1 and greater relapse at T2 as compared to COA. The reduction in airway volume at T1 was 0.56mm/mm setback in COA compared to 1.06mm/mm setback in SFOA (P-value > 0.05). The relapse in airway volume at T2 was 0.15mm/mm setback in COA compared to 0.25mm/mm setback in SFOA (P-value > 0.05). The reduction in area at T1 was 0.062mm/mm setback in COA compared to 0.110mm/mm setback in SFOA (P-value > 0.05). The relapse in area at T2 was 0.016mm/mm setback in COA compared to 0.034/mm setback in SFOA (P-value < 0.05). In setback cases, SFOA has greater airway reduction immediate post-surgically and greater relapse at 01-year follow-up. Predicting these changes at diagnostic and treatment planning stage may prevent potential adverse events on airway.

Lefort I osteotomy in combination with modified Wassmund technique: A new combination for surgery- first orthognathic approach

Objective: The aim of this technical note is to present a unique combination of orthognathic surgery which incorporates Wassmund technique and Lefort I osteotomy a part of surgery- first orthognathic approach (SFOA) in prognathic maxilla.Methods: Usually, the SFOA indications are minimally involved skeletal discrepancy and most often procedure is bilateral sagittal split ramus osteotomy (BSSRO) for setback or Lefort I osteotomy with superior repositioning. The current report illustrated SFOA in case of gummy smiling with maxillary anteroposterior excess. We have used Lefort I osteotomy in conjunction with Wassmund procedure (incorporating our own modification) for setback of premaxilla in SFOA.Results: The gummy smile was reduced from 9 mm to 3 mm with excellent occlusion in one surgery with improved psychological benefit to the patient.Conclusion: In contrast to the limited skeletal abnormality as an indication of SFOA, the current report presentation reveals a unique technique for dealing with a large skeletal discrepancy with the combination of Lefort I osteotomy and Wassmund technique. A growing acceptance in surgical and orthodontic communities toward SFOA lead an increasing demand in the patients with wide range of skeletal deformity correction in a short period of time. The surgeons should not restrict his horizon to BSSRO or Lefort I osteotomy in SFOA. The comprehensive knowledge of different surgical technique can widened the extent of SFOA.

SYM2.4 Long-Term Follow Up In A Surgery-First Orthognathic Approach Without Presurgical Orthodontic Treatment

SYM2.4 Long-Term Follow Up In A Surgery-First Orthognathic Approach Without Presurgical Orthodontic Treatment