CASE REPORT

Surgery first using skeletal anchorage

with tandem mechanics for mandibular
molar distalization
Carlos Alberto Estevanell Tavares,a Miguel Angelo R. Sheffer,b and Susiane Allgayera
Porto Alegre, Rio Grande do Sul, Brazil

This case report describes the orthodontic retreatment a patient with a skeletal Class III malocclusion. The
clinical examination showed a concave profile caused by a retruded maxilla and a prognathic mandible, an
occlusal cant, and absence of all first premolars. A surgery-first approach was combined with skeletal anchorage
implants in the maxillary arch and tandem mechanics. The esthetic facial profile, pleasant smile, appropriate
occlusion, and overall good treatment outcomes remained stable 5 years after active orthodontic treatment.
(Am J Orthod Dentofacial Orthop 2018;153:118-30)

R
ecently, surgery-first orthognathic treatment temporary device enables predictable 3-dimensional
followed by orthodontics to align, level, and movement of the entire dentition in nongrowing patients,
stabilize the occlusion has raised noticeable thereby widening the primary indications for the surgery-
interest1-10 because this approach corrects the first approach.9,13-16 In compliance with these principles,
skeletal problem from the beginning, promotes we adapted tandem mechanics to be supported by a
rapid improvement in facial esthetics, produces skeletal anchorage.17,18
psychosocial benefits,8-10 and greatly reduces the The tandem approach for intraoral distalization,
treatment time.3-10 originally described by Haas,18 is traditionally a me-
The following primary indications have been pro- chanics system anchored by cervical headgear. This
posed for the surgery-first approach: (1) moderate or biomechanical strategy involves selective deployment
minimal crowding and adequate inclination of mandib- and use of mechanical forces to simultaneously initiate
ular anterior teeth, (2) at least 3 stable occlusal stops be- various groups of tooth movements in both dental
tween the maxillary and mandibular arches, (3) little or arches.
no transverse discrepancy, and (4) an adequate curve This article describes the surgery-first approach
of Spee.1,4,7,11,12 combined with the skeletal anchorage mechanics to
In addition, with the aid of a skeletal anchorage, the treat a patient with a skeletal Class III malocclusion.
arch length can be increased by postsurgical distalization The treatment included tandem mechanics for
of the posterior teeth to accommodate crowded teeth mandibular molar distalization, and it resulted in
and still achieve proper axial incisor inclinations. This improved esthetics and occlusal stability in a 5-year
follow-up. See Supplemental Materials for a short
video presentation about this study.
a
Private practice, Porto Alegre, Rio Grande Do Sul, Brazil; Department of Ortho-
dontics, Associaç~ao Brasileira de Odontologia, Seç~ao Rio Grande do Sul, Porto
Alegre, Rio Grande do Sul, Brazil. DIAGNOSIS AND ETIOLOGY
b
Private practice, Porto Alegre, Rio Grande do Sul, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of A male patient, aged 17 years, came for ortho-
Potential Conflicts of Interest, and none were reported. dontic treatment with the chief complaint of the
Address correspondence to: Susiane Allgayer, Clınica Tavares Ortodontia e appearance of his teeth; he wanted to improve his
Odontopediatria, Rua Furriel Luiz Ant^ onio de Vargas, 250/1404, Porto Alegre
CEP 90470-130, RS, Brazil; e-mail, [email protected]; susiane. face. He reported that he had undergone a 3-year
[email protected]. orthodontic treatment 3 years earlier. The facial
Submitted, February 2016; revised and accepted, September 2016. photographs showed proportional facial thirds, a
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved. concave profile, a deficient smile, and an occlusal
http://dx.doi.org/10.1016/j.ajodo.2016.09.035 cant. The upper lip was retruded 4 mm and the lower
118
Tavares, Sheffer, and Allgayer 119

Fig 1. Pretreatment facial and intraoral photographs; facial photographs show the occlusal cant to the left.

Fig 2. Initial dental casts.

American Journal of Orthodontics and Dentofacial Orthopedics January 2018  Vol 153  Issue 1
120 Tavares, Sheffer, and Allgayer

Fig 3. A and B Initial lateral cephalometric radiograph and tracing; C, panoramic radiograph; D-F, peri-
apical radiographs.

lip 2 mm in relation to the S line. The intraoral pho- IMPA, 77 ). Considering the values of the occlusal
tographs and dental casts showed complete Class III plane angle (Occl:SN, 11 ), mandibular plane
molar and canine relationships, 2-mm overjet, (GoGn:SN, 33 ), and y-axis (y-axis to FH, 56 ), a pre-
edge-to-edge overbite, and 2-mm deviation of the dominantly horizontal growth pattern was inferred.
maxillary midline to the left side. Compensations The McNamara analysis19 showed maxillary retrusion
in the mandibular arch were accompanied by crowd- in relation to the cranial base (Co-A, 88 mm; A-
ing and a tooth-size discrepancy of 5 mm (Figs 1 NPerp, 4 mm), mandibular protrusion in relation
and 2). to the cranial base (Co-Gn, 135 mm; Pog-Nperp,
The cephalometric analysis showed a Class III jaw- 10 mm), as well as a remarkable maxillomandibular
base relationship (ANB angle, 4 ; Wits appraisal, discrepancy: Co-A–Co-Gn, 47 mm, when the normal
10 mm). The maxillary incisors were buccally tip- range is 30 to 33 mm. The panoramic radiograph
ped and protruded; the mandibular incisors were ret- showed all teeth, except that the 4 first premolars
ruded (1:NA, 8 mm and 35 ; 1:NB, 4 mm and 15 ; were absent (Fig 3; Table).

January 2018  Vol 153  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tavares, Sheffer, and Allgayer 121

for placement of plates before orthognathic sur-

Table. Cephalometric summary
gery, and worsens the deformity in the presurgical
Measurement Norm Pretreatment Posttreatment period,1,6,20 all of which were unacceptable to the
SNA ( ) 82 79 82 patient.
SNB ( ) 80 83 82 2. Surgery-first approach combined with skeletal
ANB ( ) 2 4 0
1-NA (mm) 4 8 7
anchorage orthodontic treatment. Cephalometric
1:NA ( ) 22 35 25 analysis, dental cast predictions, and simulation
1-NB (mm) 4 4 4.5 on profile images of the patient surgically treated
1:NB ( ) 25 15 20 on software (Dolphin Imaging and Mangement So-
1:1 ( ) 131 130 131 lutions, Chatsworth, Calif) were used for treatment
Occl:SN ( ) 14 11 12
GoGn.SN ( ) 32 33 37
planning. The cephalometric analysis and the Wits
S-LS (mm) 0 4 0 appraisal indicated the need for a segmented LeFort
S-LI (mm) 0 2 1 I maxillary osteotomy with 7 mm of advancement
Y-axis to FH ( ) 59.4 56 54 and bilateral sagittal split osteotomies for correction
NPog.FH ( ) 87.8 93 95 of the occlusal plane.1,8,9 Since the patient already
Angle of convexity ( ) 0 14 7
Wits (mm) 1.17 10 1.5
had received orthodontic treatment, he was
FMA ( ) 25 27 28 concerned about undergoing it again, and he
FMIA ( ) 65 76 74 chose the surgery-first approach as a treatment
IMPA ( ) 90 77 78 option because it addressed his chief complaints
Nasolabial angle ( ) 102 100 95 while minimizing the time with fixed orthodontic
A-NPerp (mm) 1 4 3
Co-A (mm) 88 94
appliances.
Co-Gn (mm) 135 135 All third molars were extracted to facilitate distal
AIFH (mm) 76 78
Pog-NPerp (mm) 2a2 10 13
movement of the posterior teeth, allowing decompensa-
tion of the mandibular incisors followed by retroclina-
AIFH, Anterior facial height; Occl:SN, occlusal plane angle; Pog- tion of the maxillary incisors.9 A transpalatal bar was
Nperp (mm), distance from pogonion to N-perpendicular to Frank-
manufactured to control the maxillary arch transverse
fort plane line.
dimension.

TREATMENT PROGRESS
TREATMENT OBJECTIVES
The treatment objectives were to (1) correct the Before orthognathic surgery, the first molars
maxillomandibular discrepancy to obtain a normal oc- were banded with palatal convertible tubes (Ormco,
clusion, (2) resolve crowding in the mandibular arch, Glendora, Calif) to fit a removable transpalatal bar.7
(3) achieve ideal overjet and overbite, (4) correct the Ceramic 0.022-in preadjusted brackets (Clarity Roth pre-
maxillary midline deviation, (5) improve function, and scription; 3M, St Paul, Minn) were then bonded to all re-
(6) improve facial esthetics. maining teeth, and passive rectangular 0.018 3 0.026-
in stainless steel archwires with surgical hooks were
TREATMENT ALTERNATIVES inserted.
Dental cast surgery was performed according to the
Analysis of the occlusion, cephalometric findings,
cephalometric prediction, and intermediate and final
facial analysis, and dental casts were determinants for
surgical splints were fabricated to ensure optimal posi-
surgical correction to achieve optimal esthetic and func-
tioning and stabilization of the jaws (Figs 4 and 5).1,7,9
tional results. The following alternatives were presented
The planned surgery was transferred to the operating
to the patient.
room by the surgical splints.2
1. Conventional surgery approach. Since the premo- Surgery was performed including bilateral sagittal
lars had been previously extracted, extractions to spilt osteotomy procedures using the intermediate splint
solve crowding in the mandibular arch followed to achieve the planned mandibular position, allowing
by orthognathic surgery to obtain normal occlu- mandibular centering (Fig 4). The splint was removed
sion were contraindicated. Notwithstanding, the when the mandibular position was stabilized with rigid
teeth could still be moved with skeletal anchorage internal fixation (Fig 5, A and B). Next, a segmented
into ideal positions in relation to their respective LeFort I maxillary osteotomy with 7 mm of advancement
bones before surgery. However, this is a time- was performed as planned oyin the Dolphin software.
consuming process,1 requires additional surgery The final splint was used to hold the new maxillary

American Journal of Orthodontics and Dentofacial Orthopedics January 2018  Vol 153  Issue 1
122 Tavares, Sheffer, and Allgayer

Fig 4. Intraoral photographs showing the intermediate splint used to achieve the planned mandibular
position for the bilateral sagittal split osteotomy procedures.

Fig 5. Trans-surgical photographs showing: A and B, bilateral sagittal split osteotomy for mandibular
centering with intermediate splint; C-E, LeFort I osteotomy with final splint in place; F, final occlusion
and final splint after surgery.

position, and titanium miniplates were used for rigid splint were removed for seating the elastics for
internal fixation (Fig 5, C-F).2,7,9 occlusal settling.9
The third molars were extracted; at the same time, Alignment and leveling were performed using 0.014
titanium straight Champy miniplates (Neodent ortho- to 0.020-in nickel-titanium archwires in both arches. A
dontics anchorage system; Neoortho, Curitiba, Brazil) transpalatal arch was placed to control the transverse
were implanted in the zygomatic buttresses (Fig 5, C- dimension,7 and a postsurgical panoramic radiograph
E) using titanium monocortical screws (2 mm diameter, was taken (Figs 7 and 8).
5 mm long). Immediately after surgery, the patient had After that, a sequence of 0.014 to 0.020-in stain-
a Class I profile and a Class II canine relationship (Fig less steel archwires (3M Unitek, Monrovia, Calif) with
6).9 an expanded omega loop were used in the mandib-
Postsurgical orthodontic treatment plays a vital role ular arch to decompensate the incisors, eliminate
in controlling dental alignment, leveling, incisor decom- crowding, and provide alignment and leveling while
pensation, arch coordination, and stabilization of the controlling the incisor angulation. Before the Class
occlusion.3,10 In compliance with these principles, III profile could relapse by decompensation of the
postsurgical orthodontic treatment was resumed mandibular incisors, causing negative overjet and
2 months after surgery when the rigid fixation and the anterior crossbite, distalization of both dental arches

January 2018  Vol 153  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tavares, Sheffer, and Allgayer 123

Fig 6. Postsurgical intraoral photographs immediately before placement of elastics for occlusal settling.

connecting the maxillary canines with the infrazygo-

matic miniplates and the mandibular arch with elastics.
At this time, the maxillary midline deviation had been
corrected.
Coordination of the maxillary and mandibular arches
was followed by finishing and detailing of the occlu-
sion.9 After a total treatment time of 24 months, all
brackets were debonded, and the titanium miniplates
were removed under local anesthesia. A wraparound
retainer was placed in the maxillary arch, and a lingual
Fig 7. Postsurgical panoramic radiograph. retainer was bonded in the mandibular anterior
segment.9

was performed simultaneously. Closed-coil springs TREATMENT RESULTS

were attached to the maxillary canine region, and a The posttreatment photographs confirmed that
distalizing force of 150 g was applied on the buccal good esthetic results and dental relationships were
side to the first hook of the bilateral infrazygomatic achieved (Figs 9-11). The posttreatment intraoral
miniplates.9 Tandem mechanics were then used by photographs and dental casts showed bilateral Class I
extending a quarter-inch latex elastic from the molar and canine relationships with good
tube on the maxillary second molar to load the dis- interdigitation of the lateral segments and ideal
talizing force to the loop on the mandibular arch overjet and overbite.
(Fig 8).17,18 The panoramic radiograph confirmed the correct
Throughout these Class III elastics mechanics, both parallel root positioning, and lateral radiographs,
molars and premolars were distalized with cephalometric tracings, and superimpositions
0.019 3 0.025-in teardrop-loop stainless steel archwires confirmed the dental and skeletal changes after treat-
by sliding mechanics supported by skeletal anchorage ment (Figs 12 and 13). The most significant
system mechanics. These mechanics contributed to tor- cephalometric changes were the 7-mm advancement
que control and bodily movement, correcting the of the maxillary base and mandibular centering. As a
lingual inclination of the mandibular incisors while result, the ANB angle increased from 4 to 0 , the
improving the inclination of the maxillary incisors. A dis- Wits appraisal increased from 10 to 1.5 mm. The
talization force was continued on both arches by maxillary retrusion decreased in relation to the cranial

American Journal of Orthodontics and Dentofacial Orthopedics January 2018  Vol 153  Issue 1
124 Tavares, Sheffer, and Allgayer

Fig 8. A-C, Distalization of molar and premolars with tandem mechanics; D, maxillary occlusal view
showing the transpalatal arch in place; E, the mandibular arch is less crowded than at pretreatment
and after surgery. The mandibular left lateral incisor is aligned, and the mandibular left central incisor
and right lateral incisor are less rotated.

base (A-NPer, 3 mm), and the remarkable maxilloman- a Class II malocclusion becomes Class III immediately
dibular discrepancy decreased (Co-A–Co-Gn, 41 mm), after mandibular advancement. The skeletal anchorage
thus making the profile straight. The superimposition system must then be used to correct the intentionally
showed distal translation of the mandibular molars created Class III or Class II malocclusion by moving pos-
without extrusion or tipping, thus reflecting distaliza- terior teeth to achieve a final Class I relation-
tion of the entire mandibular dentition. The maxillary ship.6,13,15,16,21
and mandibular incisors improved their positions in However, the most common combination of vari-
the basal bone by correcting the inclinations (1:NA, ables for a Class III malocclusion is a retruded maxilla,
7 mm and 25 ; 1:NB, 4.5 mm and 20 ; IMPA, 78 ) a protruded mandible, protruded maxillary incisors,
(Fig 13; Table). retruded mandibular incisors, and a long lower facial
Regarding function, incisal guidance in anterior height.20 For instance, the deficiency in the antero-
excursion and canine guidance in lateral movement posterior direction in the middle facial third was
were achieved (Fig 10). Furthermore, the facial profile easily identified in this patient, manifested by the
was more harmonious (Figs 1, A, and 9, A), consid- deep paranasal and infraorbital regions, deep nasoge-
ering the upper lip advancement of 4 mm, achieving nian grooves, lack of support to the upper lip, and
0 mm in relation to the S line (Fig 13). Retention re- thin nasal base (Fig 1, A-C). These features required
cords obtained 5 years after debonding showed gener- maxillary advancement, combined with bilateral
ally stable results, with a slight deviation of the sagittal split osteotomy for occlusal cant correction
mandibular dental midline. The posttreatment stabil- to improve the patient's profile.22 Consequently, the
ity can also be noticed in the distalized mandibular Class III became a Class II canine relationship (Fig
molars (Fig 14).9 5, D and F). This approach agrees with the study of
Huang et al,6 who concluded that “in surgical correc-
DISCUSSION tion of mandibular retrognathism, bimaxillary or-
The authors of previous studies have shown that thognathic surgery should be considered instead of
when surgery is performed first, a Class III malocclusion mandibular advancement. Therefore, orthognathic
becomes a Class II relationship immediately after the surgery to correct skeletal Class III or Class II maloc-
mandibular setback, requiring Class II orthodontic clusion should not be limited to using mandibular os-
mechanics after surgery.9 In the same paradigm shift, teotomy only. Mandibular osteotomy alone creates a

January 2018  Vol 153  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tavares, Sheffer, and Allgayer 125

Fig 9. Posttreatment facial and intraoral photographs. Notice the good occlusal relationship achieved.

more difficult occlusal problem for the orthodontist initiate various groups of tooth movements in both
to treat following surgery.” dental arches. Its main objective is to gain sufficient
Despite the achievement of a Class II canine rela- increases in the anteroposterior and mediolateral
tionship after the surgery-first approach, which pro- dimensions of both arches, so that the amount of
moted a straight profile (Fig 9, A), the posterior teeth space created allows repositioning of abnormally
still remained in a flush terminal plane molar relation- displaced units into their normal occlusal and
ship due to the amount of pretreatment discrepancy interincisal relationships.17,18 However, maxillary
between the maxillary and mandibular first molars miniplates were used instead of mandibular
(Fig 6, A-C). Traditionally, according to the skeletal temporary devices for this en-masse distalization in
anchorage system mechanics, mandibular anchor both dental arches. This means that temporary devices
plates are used to distalize the mandibular mo- in the mandibular arch are not necessary to distalize the
lars.9,13,15 In compliance with these principles, a great mandibular teeth. Therefore, there is no need for place-
amount of distal movement was achieved using the ment and removal of mandibular plates or mini-
tandem mechanics approach. This biomechanical implants as indicated in other studies (Figs 7, A, and
strategy uses mechanical forces to simultaneously 12, C).3,15,23,24

American Journal of Orthodontics and Dentofacial Orthopedics January 2018  Vol 153  Issue 1
126 Tavares, Sheffer, and Allgayer

Fig 10. Final photographs of excursive movements showing anterior and lateral functional guidance.
Protrusive mandibular movements: A, right view; B, left view. Canine disocclusion of all teeth in right
laterality: C, right side. Canine disocclusion in left laterality: D, left side.

Fig 11. Final dental casts.

In our patient, the mandibular incisors were incisors in a patient with a Class III malocclusion, as
extremely retroclined compared with previous reports in this one, would be a contraindication for surgery-
(1:NB, 4 mm and 15 ; IMPA, 77 ), and were severely first treatment.7 Nevertheless, use of tandem Class
crowded.1,2,7,9 According to the primary indications III mechanics17,18 prevented a negative overjet
previously cited, the surgery-first approach is recom- after surgery and any deterioration in the profile
mended for moderate or minimal crowding and during incisor decompensation (Fig 8, A-C).1,5,9,22
adequate inclination of mandibular anterior teeth. Decompensation can be performed effectively and
The excessive labial inclination of the mandibular efficiently with tandem mechanics, as shown by

January 2018  Vol 153  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tavares, Sheffer, and Allgayer 127

Fig 12. A, Final lateral cephalometric radiograph; B, final lateral cephalometric tracing; C, panoramic
radiograph; D-F, periapical radiographs.

the superimposition (Fig 13, C).9 These results may plates9,13 should be considered, as for this patient,
expand the indications for the surgery-first in whom a nonextraction approach for
approach in patients with severe crowding.7 decompensation was mandatory. However, the total
In this context, the need for distal movement of the treatment time was even shorter than published
entire mandibular dentition to achieve a Class I rela- treatment times for conventional orthognathic
tionship solved the excessive labial inclination of the surgery.1,8,9
mandibular incisors (Fig 1, D), and the amount of In this context, the treatment time is high-
mandibular crowding (Figs 1, I, and 6, E) in a manda- lighted among the great advantages of surgery-
tory nonextraction approach required more than the first treatment compared with the conventional
usual 12-month time reported by previous au- approach.4-11 A time-consuming treatment can be
thors.1,6,7,9 As mentioned by Uribe et al,1 if crowding reduced by dental repositioning achieved by sur-
is so severe as to cause an anterior crossbite and unes- gery and by the effect of the regional acceleratory
thetic profile, distalization of teeth with zygomatic phenomenon. The regional acceleratory

American Journal of Orthodontics and Dentofacial Orthopedics January 2018  Vol 153  Issue 1
128 Tavares, Sheffer, and Allgayer

Fig 13. Superimposition of tracings before treatment (black line) and after treatment (red line): A, cranial
base superimposition to evaluate surgical changes in bone and soft tissues; B, maxillary superimposition;
C, mandibular superimposition to evaluate tooth movement, extrusion, and incisor repositioning. Notice the
molar distalization and the incisor decompensation (from 1:NB, 4 mm and 15 ; IMPA, 77 ; to 1:NB, 4.5 mm
and 20 ; IMPA, 78 ).

phenomenon is a complex physiologic process that outcomes by the tandem mechanics approach (Fig
involves rapid bone remodeling and loss of regional 6, A and C).3,6,8
bone density. Clinically, it may accelerate ortho-
dontic tooth movement.3,8,11 Histologically, more
active and extensive bone remodeling was CONCLUSIONS
observed after the osteotomy.5 The combination of surgery first, skeletal anchorage,
Finally, the challenging step of predicting the and tandem mechanics proved to be an excellent
final occlusion based on the current position of the approach to treat a patient with a skeletal Class III
teeth requires precise and accurate diagnosis and malocclusion. Tandem mechanics supported by the skel-
planning.1,8,9 Orthodontists should be aware of the etal anchorage system implanted only at the maxilla
orthognathic principles and limits of orthodontic enabled 3-dimensional control for movement of the
movement, and must be experienced and skilled entire dentition. The rapid profile improvement pro-
with the skeletal anchorage system technique, moted by the surgery-first approach and the tandem
which is essential to achieve predictable 3- mechanics supported by the skeletal anchorage system
dimensional molar movement.8,9 Both the surgeon reduced the total treatment time.
and the orthodontist using the surgery-first Decompensation after surgery first can be performed
approach should be qualified and should communi- effectively and efficiently with tandem mechanics. Even
cate effectively to fixate the miniplates in the right if fixated only in the maxilla, the skeletal anchorage sys-
place. As in this patient, these temporary anchorage tem solves crowding and controls mandibular incisor
devices were fixated in a specific fashion—parallel to inclination, preventing a negative overjet even in pa-
the occlusal plane between the maxillary and tients with extremely retroclined mandibular incisors,
mandibular arches—to apply all required vectors severe crowding, and the impossibility of premolar
and thus achieve predictable and satisfactory extraction.

January 2018  Vol 153  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Tavares, Sheffer, and Allgayer 129

Fig 14. Facial and intraoral photographs 5 years after treatment.

SUPPLEMENTARY DATA “surgery-first” approach in the management of unilateral condylar

hyperplasia. Am J Orthod Dentofacial Orthop 2015;148:1054-66.
Supplementary data related to this article can be 3. Aristizabal JF, Martinez Smit R, Villegas C. The “surgery first”
found at http://dx.doi.org/10.1016/j.ajodo.2016.09. approach with passive self-ligating brackets for expedited treatment
035. of skeletal Class III malocclusion. J Clin Orthod 2015;49:361-70.
4. Kim CS, Lee SC, Kyung HM, Park HS, Kwon TG. Stability of
mandibular setback surgery with and without presurgical ortho-
dontics. J Oral Maxillofac Surg 2014;72:779-87.
REFERENCES
5. Yuan H, Zhu X, Lu J, Dai J, Fang B, Shen SG. Accelerated orthodon-
1. Uribe F, Agarwal S, Shafer D, Nanda R. Increasing orthodontic and tic tooth movement following Le Fort I osteotomy in a rodent
orthognathic surgery treatment efficiency with a modified model. J Oral Maxillofac Surg 2014;72:764-72.
surgery-first approach. Am J Orthod Dentofacial Orthop 2015; 6. Huang C, Hsu S, Chen YR. Systematic review of the surgery-first
148:838-48. approach in orthognathic surgery. Biomed J 2014;37:184-90.
2. Janakiraman N, Feinberg M, Vishwanath M, Jayaratne YS, 7. Uribe F, Janakiraman N, Shafer D, Nanda R. Three-dimensional
Steinbacher DM, Nanda R, et al. Integration of 3-dimensional cone-beam computed tomography-based virtual treatment plan-
surgical and orthodontic technologies with orthognathic ning and fabrication of a surgical splint for asymmetric patients:

American Journal of Orthodontics and Dentofacial Orthopedics January 2018  Vol 153  Issue 1
130 Tavares, Sheffer, and Allgayer

surgery-first approach. Am J Orthod Dentofacial Orthop 2013; 15. Sugawara J. Dr. Junji Sugawara on the skeletal anchorage system.
144:748-58. Interview by Dr. Larry W. White. J Clin Orthod 1999;33:689-96.
8. Hernandez-Alfaro F, Guijarro-Martınez R, Molina-Coral A, Badıa- 16. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H.
Escriche C. “Surgery first” in bimaxillary orthognathic surgery. J Skeletal anchorage system for open-bite correction. Am J Orthod
Oral Maxillofac Surg 2011;69:e201-7. Dentofacial Orthop 1999;115:166-74.
9. Nagasaka H, Sugawara J, Kawamura H, Nanda R. “Surgery first” 17. Philip C. Tandem concept in the nonextraction treatment of class II
skeletal Class III correction using the skeletal anchorage system. malocclusion. Am J Orthod 1975;68:119-56.
J Clin Orthod 2009;43:97-105. 18. Haas DG. An assessment of tandem mechanics. Angle Orthod
10. Uribe F, Chugh VK, Janakiraman N, Feldman J, Shafer D, Nanda R. 1970;40:234-48.
Treatment of severe facial asymmetry using virtual three- 19. McNamara JA. A method of cephalometric evaluation. Am J Or-
dimensional planning and a “surgery first” protocol. J Clin Orthod thod 1984;86:449-69.
2013;47:471-84. 20. Ellis ER, McNamara JA Jr. Components of adult Class III open-bite
11. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Sur- malocclusion. J Oral Maxillofac Surg 1984;42:295-305.
gery-first accelerated orthognathic surgery: postoperative rapid 21. Sugawara J, Kanzaki R, Takahashi I, Nagasaka H, Nanda R. Distal
orthodontic tooth movement. J Oral Maxillofac Surg 2011;69: movement of maxillary molars in nongrowing patients with the
771-80. skeletal anchorage system. Am J Orthod Dentofacial Orthop
12. Baek SH, Ahn HW, Kwon YH, Choi JY. Surgery-first approach in 2006;129:723-33.
skeletal class III malocclusion treated with 2-jaw surgery: evalua- 22. Menezes LM, Rizzatto SM, Allgayer S, Heitz C, Burnett LH Jr. The
tion of surgical movement and postoperative orthodontic treat- importance of interdisciplinary approach for managing cleft lip
ment. J Craniofac Surg 2010;21:332-8. and palate: a case report. JWFO 2012;1:e103-13.
13. Sugawara J, Daimaruya T, Umemori M, Nagasaka H, Takahashi I, 23. Chen K, Cao Y. Class III malocclusion treated with distalization
Kawamura H, et al. Distal movement of mandibular molars in adult of the mandibular dentition with miniscrew anchorage: a 2-
patients with the skeletal anchorage system. Am J Orthod Dento- year follow-up. Am J Orthod Dentofacial Orthop 2015;148:
facial Orthop 2004;125:130-8. 1043-53.
14. Sugawara J, Baik UB, Umemori M, Takahashi I, Nagasaka H, 24. Roberts WE, Viecilli RF, Chang C, Katona TR, Paydar NH. Biology
Kawamura H, et al. Treatment and posttreatment dentoalveolar of biomechanics: finite element analysis of a statically determinate
changes following intrusion of mandibular molars with applica- system to rotate the occlusal plane for correction of a skeletal Class
tion of a skeletal anchorage system (SAS) for open bite correction. III open-bite malocclusion. Am J Orthod Dentofacial Orthop 2015;
Int J Adult Orthod Orthognath Surg 2002;17:243-53. 148:943-55.

January 2018  Vol 153  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics