Author’s Accepted Manuscript

Orthognathic surgery for the invisalign patient

Daniel I. Taub, Victoria Palermo

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To appear in: Seminars in Orthodontics
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 Orthognathic Surgery for the Invisalign Patient

Daniel I. Taub, DDS, MD

Associate Professor
Vice Chairman & Program Director
Department of Oral and Maxillofacial Surgery
Thomas Jefferson University

Victoria Palermo, DDS, MD

Chief Resident
Department of Oral and Maxillofacial Surgery
Thomas Jefferson University

Corresponding Author:
Daniel I. Taub, DDS, MD
Associate Professor
Vice Chairman & Program Director
Department of Oral and Maxillofacial Surgery
Thomas Jefferson University
909 Walnut Street
COB, 3rd Floor
Philadelphia, PA 19107

Email: [email protected]

Tel. (215) 955-6215

Fax (215) 923-9189
 Proper treatment of malocclusions with skeletal discrepancies and dysmorphologies
oftentimes includes surgical intervention. Orthognathic surgical correction of the maxillofacial
complex is technique sensitive and requires meticulous planning. There are a limited number of
fundamental surgical techniques to reposition the maxillomandibular complex in three dimensions.
Repositioning of the maxilla and correction of the mid-face projection is predominantly achieved
utilizing LeFort osteotomy. This can be done with or without segmentation to achieve transverse
correction or segmental alignment. Similarly, repositioning of the mandible is accomplished via
mandibular ramus osteotomy. Most frequently, the technique of sagittal split ramus osteotomy is
used, but also when indicated, variations of the technique, including vertical ramus osteotomy, are
used. As both techniques achieve a three-dimensional repositioning of the skeletal units, surgical
splints are indispensable aids in the process. Typically, in the process of surgical correction of the
pitch, yaw and cant of the skeletal units, the surgeon must rely upon pre-fabricated surgical splints.
The splint is the instrument to position the occlusion of the opposing dental arches and it also
stabilizes the skeletal units at the new locus. While rigid internal fixation with bone plates and screws
provides long term stability and allows quick return to functioni,ii,iii, the splint-aided intraoperative
intermaxillary fixation within the occlusal splint is the mechanism that guides and determines the
position in which rigid fixation will be accomplishediv,v.

Pre-operative analysis and planning is done based on the clinical information collected by the
surgeon. These are similar to what the orthodontists collect: clinical photos, cephalometric
radiographs, dental models, bite registration and face bow transfer. This data, in conjunction with ex-
vivo model surgery on a semi-adjustable articulator, allows the surgeon to assess the feasibility of
required surgical intervention and to position the maxilla and/or mandible in an ideal relationship4,5,vi.
This process is a simulation of the correction for both the occlusal deformity and skeletal
discrepancy. It is the blueprint for in-vivo intervention. It cannot be overemphasized that the model
surgery performed on the articulator reflects the utmost precision and accuracy of meticulous
measurements and attention to detail to simulate surgical movements. In order to enable the transfer
of information from the mounted dental casts to the operating field, an interocclusal splint is
fabricated by the surgeon. It serves as the guide to position the free osteotomized segment with
relation to a stable skeletal point. Furthermore, in select cases, a stabilizing splint may be indicated in
the post-operative phase as well. It facilitates predictable bony healing positions. For example, cases
where the maxilla or mandible have been expanded or narrowed through a segmental approach, or
cases where stable occlusion post operatively cannot be achieved due to missing dentition or severe
tooth wear are critically dependent on the splint. Secure fixation of the interocclusal splint or
stabilization of the maxillomandibular complex in the anticipated interdigitated position is key to
obtaining predicted surgical outcomes.

More recently, with the advent and increased availability of computer tomography (CT)
imaging and technology that allows sophisticated manipulation of the generated data, virtual surgical
planning (VSP) and computer assisted design/manufacturing (CAD/CAM) of surgical splints has
gained increased acceptance within craniofacial surgeryvii,viii. This has been further reinforced with
increasing availability of data supporting the accuracy of VSPix, in addition to providing a perhaps
more consistent and comprehensive approach to treatment of complex craniofacial disorders x. The
VSP differs from traditional model surgery in that, it makes use of stone models in conjunction with
maxillofacial CT data to generate a virtual 3-dimensional model combining maxillomandibular
skeletal anatomy with dentoalveolar form. This constructed virtual model allows for manipulation
and simulation of skeletal and occlusal changes and movements. The resulting surgical plan takes
into account not only the relationship of the dental arches to each other, but also anticipated position
of the bony segments, revealing potential challenges or interferences. Once the virtual simulation is
completed, stereolithographic splints are fabricated for use during surgery, theoretically eliminating
introduction of error due to multistep nature of conventional model surgery. Despite a novel method
of surgical planning and splint fabrication, intermaxillary fixation and stabilization of the splint
remains key in achieving predicted outcomes.
Overall, the excellence of pre-surgical orthodontics is essential for the success of orthognathic
surgery, just as it is to post-surgical repositioning of teeth. The orthodontist must therefore be well
versed in the surgical techniques. Such knowledge makes the orthodontist understand and appreciate
the concessions that may be necessary secondary to the use of Invisalign therapy compared to
traditional orthodontics. These two orthodontic appliances are vastly different for the surgeon who is
managing the surgery, the healing, and the long-term stability of the correction.

Traditional orthodontic therapy with orthodontic wires provides opportunity for application of
surgical lugs or Kobayashi style ligature wires. They are most dependable and indispensable in their
utility and facilitate intraoperative maxillomandibular fixation into occlusion with opposing arch, as
well as pre-fabricated intermediate or final surgical splint. The Invisalign appliance has eliminated
such hardware; an additional challenge is now created for the surgical phase. These challenges,
however, can be easily circumvented with appropriate surgical planning and application of techniques
for maxillomandibular fixation commonly used in the setting of facial trauma. Thus, in the absence of
lugs of Kobayashi ties, intermaxillary fixation can be achieved by interdental wire fixation via Ivy
loops, application of Erich arch barsxi, the use of bonded brackets or buttons, and the use of
intermaxillary fixation screws, which may be considered under the category of temporary skeletal
anchorage devices (TADs).

Arch bars are applied to the dentition in both the maxillary and mandibular arches and secured
by circumdental wires; with inter-arch wires subsequently used to establish occlusion (Figure 1A and
1B). The draw backs of the arch bar technique include greatly increased operative time and
consequent patient exposure to extended anesthesia, trauma to the periodontium, compromised oral
hygiene, as well as increased risk of penetrating trauma to the surgeon. Interdental fixation with
eyelet or Ivy loops also relies on wires placed circumdentally, subsequently wired together to create
maxillomandibular fixation. An advantage of this technique is somewhat improved operating time
due to decreased number of circumdental wires necessary to establish stable occlusion and improved
ease or removal following the period of maxillomandibular fixation.
Recent development of intermaxillary fixation (IMF) screws, starting with initial description
of their use by Arthur and Berardo in 1989xii, provided an additional alternative to conventional arch
bar application. They decrease operating room time, facilitate easier placement, and decrease the risk
of damage to the periodontal apparatus. An additional advantage, which is of upmost importants in
elective cases, such as orthognathic surgery, is improved acceptance by patientsxiii,xiv,xv. Screws are
positioned in a bicortical fashion between the roots of the teeth at the mucogingival junction or in
attached tissue. In our experience, typically eight IMF screws are placed to provide a total of four
points of maxillomandibular fixation distributed bilaterally (Figure 2A and 2B). As all treatment
modalities have limitations and risks of distinct complications, IMF screws are not an exception and
may cause root injury18,xvi,xvii, present a risk of aspiration, screw loosening, with compromise in the
maxillomandibular fixation, and screw shearing. Recent reports of clinical studies have shown that in
comparison of self-drilling and self-tapping screws, the self-drilling screws presented an overall
better safety profilexviii. Furthermore, recent development of bone supported arch bars provides a
hybrid between circumadentally retained Erich Arch bars and fixation screws, seeking to combine the
advantages of both. Some examples of such appliances include the SmartLock Hybrid MMF (Figure
3a) , manufactured by Stryker Craniomaxillofacial, as well as the MatrixWave MMF System,
manufactured by DePuy Synthes (Figure 3b).
 Orthodontic therapy with clear aligners has shifted the paradigm in both the orthodontic
management of malocclusion and the intraoperative needs of the orthognathic surgery patient during
maxillomandibular manipulation. The evolution in software technology, specifically with
manipulation of data to create three-dimensional models, provides multidisciplinary teams with
additional opportunities to refine treatment plans through combination of orthodontic treatment
planning and virtual surgical planning. The concurrent elimination of conventional orthodontic
hardware, albeit challenging at first glance due to compromised surface for intermaxillary fixation,
fuels ingenuity in bringing the concepts of maxillomandibular fixation traditionally used in trauma
into the arena of elective orthognathic surgery. Here we presented alternative options of inter-arch
fixation that can be utilized in the setting of maxillary and/or mandibular osteotomies in the setting of
Invisalign therapy; in the process, exploring opportunities to provide expanded scope of exceptional
patient care.

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FIGURES
Figure 1: A. Occlusal scheme established with Invisalign treatment prior to maxillomandibular
advancement for correction of skeletal discrepancy. B. Erich arch bars in place, providing anchorage
for maxillomandibular fixation. Note preservation of gingival architecture and unobstructed access for
surgical incision 5 mm apical to the mucogingival junction.

Figure 2: A. Occlusal scheme established with Invisalign treatment prior to maxillomandibular

advancement for correction of skeletal discrepancy. B. Intermaxillary fixation screws in place providing
four points of maxillomandibular fixation, distributed bilaterally. C. Four screws on each side provide
two points of maxillomandibular fixation, one more anterior in the canine and first premolar region
and one more posterior in the first and second molar region.

Figure 3: Examples of commercially available bone supported arch bars. A) SmartLock Hybrid MMF
manufactured by Stryker Craniomaxillofacial B) MatrixWave MMF manufactured by DePuy Synthes.