Journal of

Clinical Medicine

Article
Modern Surgery-First Approach Concept in
Cleft-Orthognathic Surgery: A Comparative Cohort
Study with 3D Quantitative Analysis of
Surgical-Occlusion Setup
Hyung Joon Seo 1,2,† , Rafael Denadai 1,† , Betty Chien-Jung Pai 3, * and Lun-Jou Lo 1, *
1 Department of Plastic and Reconstructive Surgery, Craniofacial Research Center, Chang Gung
Memorial Hospital, Chang Gung University, Taoyuan City 33302, Taiwan; [email protected] (H.J.S.);
[email protected] (R.D.)
2 Department of Plastic and Reconstructive Surgery and Biomedical Research Institute,
Pusan National University Hospital, Busan City 49241, Korea
3 Division of Craniofacial Orthodontics, Department of Dentistry, Chang Gung Memorial Hospital,
Taoyuan City 33302, Taiwan
* Correspondence: [email protected] (B.C.-J.P.); [email protected] (L.-J.L.);
Tel.: +886-3-328-1200 (ext. 2430) (B.C.-J.P. & L.-J.L.); Fax: +886-3-327-1029 (B.C.-J.P. & L.-J.L.)
† Hyung Joon Seo and Rafael Denadai contributed equally in this study.




Received: 16 November 2019; Accepted: 29 November 2019; Published: 2 December 2019


Abstract: Despite the evident benefits of the modern surgery-first orthognathic surgery approach
(reduced treatment time, efficient tooth decompensation, and early improvement in facial esthetics),
the challenge of the surgical-occlusion setup acts as a hindering factor for the widespread and global
adoption of this therapeutic modality, especially for the management of cleft-skeletofacial deformity.
This is the first study to assess three-dimensional (3D) quantitative data of the surgical-occlusion
setup in surgery-first cleft-orthognathic surgery. This comparative retrospective study was performed
on 3D image datasets from consecutive patients with skeletal Class III deformity who had a unilateral
cleft lip/palate (cleft cohort, n = 44) or a noncleft dentofacial deformity (noncleft cohort, n = 22)
and underwent 3D computer-assisted single-splint two-jaw surgery by a single multidisciplinary
team between 2014 and 2018. They received conventional orthodontics-first or surgery-first
approaches. 3D quantitative characterization (linear, angular, and positional measurements) of
the final surgical-occlusion setup was performed and adopted for comparative analyses. In the cleft
cohort, the occlusion setup in the surgery-first approach had a significantly (all p < 0.05) smaller
number of anterior teeth contacts and larger incisor overjet compared to the conventional approach.
Considering the surgery-first approach, the cleft cohort presented significantly (all p < 0.05) larger
(canine lateral overjet parameter) and smaller (incisor overjet, maxillary intercanine distance, maxillary
intermolar distance, ratio of intercanine distance, and ratio of intermolar distance parameters) values
than the noncleft cohort. This study contributes to the literature by providing 3D quantitative data of
the surgical-occlusion setup in surgery-first cleft-orthognathic surgery, and delivers information that
may assist multidisciplinary teams to adopt the surgery-first concept to optimize cleft care.

Keywords: occlusion setup; orthognathic surgery; surgery first; modified surgery first; cleft lip/palate

1. Introduction
Cleft lip, with or without a cleft palate, is the second most common global birth defect,
affecting 1.7 in every 1000 births [1]. A substantial percentage of skeletally mature patients

J. Clin. Med. 2019, 8, 2116; doi:10.3390/jcm8122116 www.mdpi.com/journal/jcm

J. Clin. Med. 2019, 8, 2116 2 of 22

(20–75%) [2–4] present visible skeletofacial deformities and cleft-related psychosocial problems that
contribute to social discrimination and stigmatization [5,6], requiring appropriate treatment [2–4].
Orthognathic surgery (OGS) is considered the mainstay of treatment due to the positive impact
on oral function, facial appearance, and psychosocial health [7–9]. Classically, the dental arches
of patients with clefts have been orthodontically prepared before OGS [10,11]. This conventional
orthognathic pathway (or orthodontics-first approach) involves complete dental management, including
7–47 months of presurgical therapy for correction of dental compensation, arch alignment, maxillary-and
mandibular-arch coordination, and the leveling of accentuated occlusal-plane discrepancies [11–13].
However, this therapeutic method has been associated with prolonged overall treatment time [12–14].
A modern orthognathic pathway (or surgery-first approach) has recently been introduced
into the armamentarium of multidisciplinary teams treating dentoskeletofacial deformities [15–17].
Surgical intervention preceding orthodontic treatment has evident advantages over the conventional
orthodontics-first approach, including immediate postoperative improvement of facial appearance
and a substantial reduction of total treatment time [18–20]. However, the rate of surgery-first
approach-related complications may be slightly higher than those associated with orthodontics-first
approach [21], which should be considered by multidisciplinary teams delivering orthognathic care.
In this setting, published guidelines have directed multidisciplinary teams during the decision-making
process of selecting patients for the surgery-first approach [22,23]. Most surgery-first-related studies have
reported patients with Class III malocclusion with no associated congenital anomaly [18–20], with
cleft-related deformity being considered as an exclusion criterion for the surgery-first approach [24].
Patients with repaired cleft lip and palate have a significant aesthetic impairment [25] and the main
benefit of surgery-first approach is an immediate increase of the quality of life after surgery, due to the
improvement of facial appearance [26].
Recommendations have also been published to direct the surgical-occlusion setup (i.e., the
setup of the transitional occlusion at the time of surgery), the most difficult step for the surgery-first
approach [22,23,27–38]. However, most of these previous recommendations had no quantitative data
or occlusal characteristics [27–31]. Existing occlusal-related quantitative data are restricted to the
surgery-first approach in noncleft skeletal Class III deformity [38]. We are not aware of any study
focused on quantitative analysis of the surgical-occlusion setup in surgery-first cleft-orthognathic
surgery. The setting of surgical occlusion is paramount to orthognathic therapeutic flow as it serves
not only to anticipate the dental movements necessary in postsurgical orthodontic treatment, but
also to fabricate the occlusal splint that guides surgeons during operations. Therefore, definition
of quantitative data for occlusal-related parameters from a three-dimensional (3D) perspective can
support understanding the modern surgery-first pathway concept in the context of cleft-skeletofacial
deformity and also inspire the expansion of its use among multidisciplinary centers delivering cleft care.
The purposes of this study were: (1) to assess the 3D quantitative characteristics of the
surgical-occlusion setup in surgery-first cleft-orthognathic surgery; and (2) to compare these data with those
obtained from conventional cleft-orthognathic-surgery and surgery-first noncleft orthognathic-surgery
approaches. 3D quantitative-based recommendations for the surgical-occlusion setup in surgery-first
cleft-orthognathic surgery were also addressed.
A primary outcome and a secondary outcome are expected in this study:
The primary endpoint of the study is the comparison of surgical-occlusion setup between surgery-first
(experimental group) and conventional orthognathic surgery (control group) in cleft patients/cohort.
The secondary endpoint of the study is the comparison of surgical-occlusion setup between cleft
and noncleft patients/cohorts.
The null hypotheses were:
No difference of surgical-occlusion setup exists between surgery-first (experimental group) and
conventional orthognathic surgery (control group) in cleft patients/cohort.
No difference of surgical-occlusion setup exists between cleft and noncleft patients/cohorts.
J. Clin. Med. 2019, 8, 2116 3 of 22

2. Material and Methods

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines
were used for reporting the results of this institutional review board–approved (Chang Gung Medical
Foundation, protocol 201900008B0) comparative retrospective study. Consecutive skeletally mature
patients (finished their growth spurt with no more increase in body height) with Class III occlusion
were recruited who had unilateral complete cleft lip/palate (cleft cohort) or noncleft deformity
(noncleft cohort) undergoing orthodontic-surgical treatment by the Chang Gung multidisciplinary
team between 2014 and 2018. All included patients were treated by the same orthodontist (B.C.-J.P.) and
surgeon (L.-J.L.). Demographics (age and gender), orthodontic-surgical (dental characteristics, type
of orthognathic approach, time of presurgical therapy, and need for revision bone and/or soft tissue
surgery to improve occlusal, maxillary, mandibular, and/or chin morphology within the follow-up),
and cone beam computed tomography (CBCT) scan data were retrieved from the Craniofacial Research
Center database.
Exclusion criteria were patients with Class I or II skeletal patterns; bilateral cleft deformity; any
syndromic diagnosis; previous orthognathic surgery; and/or an incomplete medical/3D image record.
Patients who underwent segmental osteotomies (surgically assisted maxillary expansion, anterior
subapical osteotomy, and/or segmented maxillary osteotomies) were also excluded.
Sixty-six patients with cleft (n = 44; 50% female; 19 ± 4 (15–23) years at surgery; 66% with
left-sided clefts) and noncleft (n = 22; 50% female; 22 ± 5 (15–27) years at surgery) deformities met the
described criteria.

2.1. Orthognathic-Surgery Treatment

Full descriptions of the pre- and postorthognathic-treatment principles used in this center
were previously published [22,23,28,32–43]. After a short period of orthodontic preparation for
secondary alveolar bone grafting (9-year-old patients), no further surgical intervention or orthodontic
treatment have been performed in patients with unilateral cleft lip/palate who present signs of
skeletofacial deformity such as Class III skeletal pattern. The orthognathic surgery treatment process
has been started when the patients reach the skeletal maturity (>15 and 18 years for female and male
patients, respectively).
All included patients were surgically treated by using 3D computer-assisted single-splint two-jaw
orthognathic surgery [38–41]. Selected patients were orthodontically managed by using conventional
orthodontics-first or surgery-first approaches [22,23,28,32–37] based on dentition status at presentation:

(a) In the conventional approach, surgery was performed after a period of at least seven months of
complete orthodontic therapy, including the leveling and alignment of dental arches to eliminate
any occlusal interference at surgery, and the removal of all dental compensations to maximize
optimal surgical repositioning of the jaws.
(b) Patients with different compositions of the dental conditions (Table 1) received the surgery-first
orthognathic treatment based on a patient-specific therapeutic planning (Figure 1). Patients with
more and less favorable dental conditions received the surgery-first treatment as it was based on
the orthodontist’s judgment of achievement of a practicable surgical-occlusion setup as well as
anticipation of a feasible postoperative orthodontic treatment. Our team stratified the surgery-first
approach into two models. In the standard surgery-first model, surgery was performed with
no need for presurgical orthodontic therapy. In the modified surgery-first model, a short period
(≤6 months) of orthodontic therapy was performed preoperatively. This presurgical dental
adjustment was exclusively implemented for the reduction of potential dental collisions and the
minimal decompression of mandibular teeth.

In this study, the 3D quantitative data of standard and modified surgery-first models were initially
compared. Both models were then compiled as a unique dataset (surgery-first approach) and adopted
for comparative analysis between surgery-first and conventional approaches.
 Curve of Spee
Cleft side n (%)
Mild/Moderate/Severe 10 (47.6%)/8 (38.1%)/3 (14.3%)
Noncleft side n (%)
Mild/Moderate/Severe 11 (52.4%)/7 (33.3%)/3 (14.3%)
Posterior crossbite (molar)
Cleft side (Yes/No) n (%) 9 (42.9%)/12 (57.1%)
J. Clin. Med. 2019, 8, 2116 4 of 22
Noncleft side (Yes/No) n (%) 7 (33.3%)/14 (67.7%)
n, number of patients; m, mean; sd, standard deviation; mm, millimeters.

Figure 1. Basic
Figure 1.illustrative schemes
Basic illustrative portraying
schemes portraying general
general dental(left)
dental elements: elements: (left)
curve of Spee; curve of Spee;
(middle)
anterior-teeth alignment; and (right) incisor inclination, adopted to distingue (top) more favorable
(middle) anterior-teeth alignment; and (right) incisor inclination, adopted to distingue (top) more
favorable (minimal anterior dental crowding, flat-to-mild curve of Spee, and normal range of angle
between basal bone and upper and lower incisors) and (bottom) less favorable dentition status for
management by the surgery-first orthognathic approach. As there is broad clinical presentation with
variable degrees of association between these dental elements, patient-specific diagnosis and tailored
therapeutic planning should be established in a case-by-case basis.

Table 1. Spectrum of dental characteristics in cleft cohort before surgery-first model treatment.

Parameters Cleft Cohort (n = 21)

Maxillary dentition
Missing tooth
Yes/No n (%) 12 (57.1%)/9 (42.9%)
Lateral incisor n (%) 12 (57.1%)
Central incisor n (%) 1 (4.8%)
First premolar n (%) 1 (4.8%)
Spacing
Yes/No n (%) 3 (14.3%)/18 (85.7%)
Anterior crowding
Yes/No n (%) 21 (100%)/0 (0%)
Mild/Moderate/Severe n (%) 6 (28.6%)/8 (38.1%)/7 (33.3%)
Posterior crowding
Yes/No n (%) 9 (42.9%)/12 (57.1%)
Mild/Moderate/Severe n (%) 5 (55.6%)/2 (22.2%)/2 (22.2%)
Incisor relation
Overjet
Negative/Positive n (%) 21 (100%)/0 (0%)
Negative/Positive (mm) m ± sd −5.5 ± −3.8/–
Overbite
Negative/Positive n (%) 3 (14.3%)/18 (85.7%)
Negative/Positive (mm) m ± sd −4.7 ± −1.5/2.6 ± 1.8
Upper midline deviation
Yes/No n (%) 17 (81%)/4 (19%)
Yes/No (mm) m ± sd 3.2 ± 1.8/–
Curve of Spee
Cleft side n (%)
Mild/Moderate/Severe 10 (47.6%)/8 (38.1%)/3 (14.3%)
Noncleft side n (%)
Mild/Moderate/Severe 11 (52.4%)/7 (33.3%)/3 (14.3%)
Posterior crossbite (molar)
Cleft side (Yes/No) n (%) 9 (42.9%)/12 (57.1%)
Noncleft side (Yes/No) n (%) 7 (33.3%)/14 (67.7%)
n, number of patients; m, mean; sd, standard deviation; mm, millimeters.
 variable degrees of association between these dental elements, patient-specific diagnosis and tailored
therapeutic planning should be established in a case-by-case basis.

In this study, the 3D quantitative data of standard and modified surgery-first models were
initially
J. compared.
Clin. Med. 2019, 8, 2116Both models were then compiled as a unique dataset (surgery-first approach) and
5 of 22
adopted for comparative analysis between surgery-first and conventional approaches.

2.2. 3D-Image Acquisition

One month before surgery,
surgery, aa standard
standard craniofacial
craniofacial CBCT
CBCT scan
scan was
was performed
performed for each
each patient
patient
using an i-CAT 3D Dental Imaging System (Imaging Sciences International, Hatfield, PA, USA) with
the following
following parameters:
parameters:120 120kVp,
kVp,0.40.4
mm mm × mm
× 0.4 × 0.4×mm
0.4 mm 0.4voxel
mm voxel
size, 40size, 40 time,
s scan s scanand
time,
a 22and
cm
a× 22 cm ×
16 cm 16 cm
field field of
of view. Theview. The patients’
patients’ head was head was positioned
positioned with thewith the Frankfort
Frankfort horizontal horizontal plane
plane parallel
parallel to the ground.
to the ground. Throughout
Throughout the scan,
the scan, patients
patients werewere instructed
instructed notnot
to to swallow,totokeep
swallow, keeptheir
their mouth
closed,
closed, and
andto tomaintain
maintaina acentric
centricocclusion
occlusionbite [32,33,38,40].
bite Images
[32,33,38,40]. were
Images stored
were in Digital
stored Imaging
in Digital and
Imaging
Communications
and Communications in the in
Medicine format and
the Medicine rendered
format into 3D volumetric
and rendered images using
into 3D volumetric the Dolphin
images 3D
using the
software package (Dolphin Imaging and Management Solutions, Chatsworth, CA,
Dolphin 3D software package (Dolphin Imaging and Management Solutions, Chatsworth, CA, USA).USA).

2.3. Final Surgical-Occlusion

2.3. Final Surgical-Occlusion Setup
Setup
Two
Two weeks
weeks before
before surgery,
surgery,the
the final
final surgical-occlusion
surgical-occlusion setup
setup was
was manually
manually performed
performed using
using the
the
dental-cast
dental-cast model
model method,
method, considering
considering dental
dental midline
midline coincidence,
coincidence, canting,
canting, and
and the
the relative
relative position
position
of
of dentitions
dentitions between
between maxillary
maxillary and
and mandibular
mandibular arches.
arches. The target was
The target to avoid
was to avoid severe
severe postoperative
postoperative
occlusal
occlusal instability, incomplete or excessive skeletal correction, or skeletofacial deformities such
instability, incomplete or excessive skeletal correction, or skeletofacial deformities such as
as
asymmetry while defining the surgical-occlusion
asymmetry while defining the surgical-occlusion setup. setup.
To
To transfer
transfer the
the dental-cast
dental-cast method
method into into aa digital
digital image,
image, the
the maxillary
maxillary andand mandibular
mandibular dental
dental
casts and the defined surgical occlusion were scanned (Figure 2) by using a
casts and the defined surgical occlusion were scanned (Figure 2) by using a surface scannersurface scanner (3-Shape,
(3-Shape,
Copenhagen,
Copenhagen, Denmark). Using Dolphin
Denmark). Using Dolphin software,
software, the
the dentition
dentition in
in CBCT
CBCT waswas superimposed
superimposed and and
replaced
replaced by a digitalized dental image [42,43]. The 3D skull models were oriented according
by a digitalized dental image [42,43]. The 3D skull models were oriented according toto the
the
Frankfort
Frankfort horizontal
horizontal and
and midsagittal
midsagittal planes.
planes. Osteotomy
Osteotomy lines
lines were
were created
created byby segmenting
segmenting the maxilla
the maxilla
(Le
(Le Fort
Fort I)
I) and
and mandible
mandible (bilateral
(bilateral sagittal
sagittal split
split osteotomy).
osteotomy). TheThe digitalized
digitalized dental
dental image
image was
was then
then
manipulated by moving the osteotomized distal mandible segment to the fixed
manipulated by moving the osteotomized distal mandible segment to the fixed maxilla for maxilla for achievement
of the desiredof
achievement final
the surgical
desired occlusion (Figures
final surgical 3–5). (Figures 3–5).
occlusion

Figure 2.2.Digitalized
Figure Digitalized dental
dental images
images displaying
displaying final surgical-occlusion
final surgical-occlusion setup forsetup for surgery-first
surgery-first approach.
approach.
 J. Clin.
J. Clin. Med.
Med. 2019,
2019, 8, 8, 2116
2116 66ofof2222

J. Clin. Med. 2019, 8, 2116 6 of 22

Figure 3. 3D maxillary and mandibular dental arch models (left) before and (right) after mobilization
of the osteotomized mandible distal segment to achieve final surgical-occlusion setup. Digitalized
3D maxillary
Figure 3. 3D maxillary and
and mandibular
mandibular dental
dental arch
arch models
models (left)
(left) before
before and (right) after
after mobilization
mobilization
dental images displayed in Figure 2.
of the osteotomized mandible distal segment to achieve
achieve final
final surgical-occlusion
surgical-occlusion setup.
setup. Digitalized
dental images displayed in Figure 2.

Figure 4. 3D maxillary and mandibular dental arch models (left) before and (right) after mobilization
ofFigure
the osteotomized mandible
4. 3D maxillary distal segment
and mandibular to achieve
dental final (left)
arch models surgical-occlusion setup.after mobilization
before and (right)
of the osteotomized mandible distal segment to achieve final surgical-occlusion setup.
Figure 4. 3D maxillary and mandibular dental arch models (left) before and (right) after mobilization
of the osteotomized mandible distal segment to achieve final surgical-occlusion setup.
J. Clin. Med. 2019, 8, 2116 7 of 22
J. Clin. Med. 2019, 8, 2116 7 of 22

Figure 5.
Figure 5. Occlusogram
Occlusogram with color map
with color map tool
tool displaying
displaying 3D 3D (top)
(top) maxillary
maxillary and
and (bottom)
(bottom) mandibular
mandibular
dental-arch models
dental-arch models (left)
(left) before
before and
and (right)
(right) after
after mandible
mandible mobilization
mobilization for
for occlusion
occlusion setup,
setup, with
with
surgical occlusal
surgical occlusalcontact
contact onon three
three segments
segments and and six teeth.
six teeth. Note
Note the the reduction
reduction of toothof toothincontact
contact in
posterior
posterior
region region
(red and (red
green and green
color) color)
due duecreation
to the to the creation of anterior-tooth
of anterior-tooth contact
contact (green(green color),
color), whichwhich
is a
is a characteristic
characteristic step adopted
step adopted for surgical-occlusion
for surgical-occlusion setup setup in surgery-first
in surgery-first approach.
approach. Red indicates
Red indicates degree
degree
of (left)of (left)collision,
dental dental collision,
which can which can bethoroughly
be (right) (right) thoroughly
adjusted adjusted before finishing
before finishing surgical-
surgical-occlusion
occlusion
setup. Forsetup. For the surgery-first
the surgery-first approach,approach, the orthodontic
the orthodontic brackets
brackets were werepreoperatively
bonded bonded preoperatively
but with
butorthodontic
no with no orthodontic tooth movement;
tooth movement; wires were wires were
placed oneplaced one day
day before beforetooth
surgery; surgery; toothextracted
#14 was #14 was
extracted during surgery; orthodontic treatment started during the healing stage by
during surgery; orthodontic treatment started during the healing stage by addressing the curve of Spee addressing the
curve
(a largeofoverjet
Spee (a waslarge overjetfor
designed wasthedesigned for the
surgery) and the surgery)
constrict and
uppertheposterior
constrictteeth
upper posterior
with teeth
trans-palatal
with appliance.
arch trans-palatal arch images
Dental appliance. Dental in
displayed images
Figuresdisplayed
2 and 3. in Figures 2 and 3.

2.4. Virtual Planning

2.4. Virtual Planning
One
One week
week before
before surgery,
surgery, 3D3D computer-assisted
computer-assisted surgical
surgical planning
planning waswas performed
performed by by the
the
surgeon
surgeon and orthodontist. To achieve a normal jaw relationship with skeletofacial harmony and
and orthodontist. To achieve a normal jaw relationship with skeletofacial harmony and
symmetry,
symmetry,the themaxillomandibular
maxillomandibular complex
complex waswas
mobilized
mobilizedwhile preserving
while the surgical-occlusion
preserving setup
the surgical-occlusion
(Figure 6) [38,40]. If any modification in the surgical-occlusion setup was judged as
setup (Figure 6) [38,40]. If any modification in the surgical-occlusion setup was judged as necessary necessary (e.g.,
surgical unfeasibility
(e.g., surgical due to inappropriate
unfeasibility initial occlusion
due to inappropriate setup), thesetup),
initial occlusion overallthe
process wasprocess
overall redesigned
was
(including a new final surgical-occlusion setup) until consensus was achieved between
redesigned (including a new final surgical-occlusion setup) until consensus was achieved between surgeon and
orthodontist. The fabrication of computer-generated 3D surgical-occlusion
surgeon and orthodontist. The fabrication of computer-generated 3D surgical-occlusion splints splints (Figure 7) was
accomplished
(Figure 7) wasby only adopting
accomplished by the
onlyfinal surgical-occlusion
adopting setup as template
the final surgical-occlusion forasadjustment
setup template forof
thickness (OrthoAnalyzer software package; 3Shape, Copenhagen, Denmark)
adjustment of thickness (OrthoAnalyzer software package; 3Shape, Copenhagen, Denmark) and and printing (Objet30
OrthoDesk 3D Printer,
printing (Objet30 Stratasys3D
OrthoDesk Ltd., Rehovot,
Printer, Israel). These
Stratasys 3D-printed
Ltd., Rehovot, final surgical-occlusion
Israel). These 3D-printedsplints
final
were adopted in the surgical procedures. No intermediate surgical-occlusion
surgical-occlusion splints were adopted in the surgical procedures. No intermediate surgical- setup or intermediate
occlusal
occlusionsplint
setupwas adopted in the
or intermediate authors’
occlusal approach.
splint was adopted in the authors’ approach.
 J. Clin. Med. 2019, 8, 2116 8 of 22

J. Clin. Med. 2019, 8, 2116 8 of 22

Figure
Figure 6. 6.
Practical
Practicalexample
example ofof3D3D computer-assisted
computer-assisted single-splint
single-splint two-jaw
two-jaw surgical
surgical simulation
simulation using
using
surgery-first
surgery-firstapproach.
approach.(Top)
(Top) Actual cleft–skeletofacial
cleft–skeletofacialdeformity
deformitywith with
LeLe Fort
Fort I, bilateral
I, bilateral sagittal
sagittal splint,
splint, and genioplasty
and genioplasty osteotomy
osteotomy lines. (Center)
lines. (Center) DefinitionDefinition of final surgical-occlusion
of final surgical-occlusion setup byof
setup by mobilization
mobilization
osteotomized of distal
osteotomized
mandibledistal mandible(Bottom)
bone segment. bone segment. (Bottom) based
Final simulation Final on
simulation based on an
an orthodontic-surgical
collaborative decision-making
orthodontic-surgical collaborative process with the maxillomandibular
decision-making process with thecomplex mobilized in translation
maxillomandibular complex
directions
mobilized inas well as roll,
translation pitch, and
directions yaw as
as well rotation movements
roll, pitch, and yaw using frontal,
rotation profile, and
movements basal
using views,
frontal,
respectively.
profile, and basal These patient-specific
views, bone mobilizations
respectively. These patient-specific were
boneaccomplished
mobilizationsbywere the accomplished
maintenance of
byosteotomized
the maintenance maxillaof and distal mandible
osteotomized bone
maxilla segments
and as a uniquebone
distal mandible unit segments
(maxillomandibular
as a unique complex)
unit
and with no modification
(maxillomandibular complex)in the final
and surgical-occlusion
with no modification setup. This
in the final-simulation
final datasetsetup.
surgical-occlusion was adopted
This
to transfer virtual
final-simulation surgery
dataset was to adopted
actual surgery. Dentalvirtual
to transfer imagessurgery
displayed to in Figures
actual 2, 3 and
surgery. 5. Single-splint
Dental images
two-jaw orthognathic
displayed in Figures 2, surgery
3 and 5.technique principle
Single-splint is displayed
two-jaw in Figures
orthognathic surgery8 and 9.
technique principle is
displayed in Figures 8 and 9.
J. Clin. Med. 2019, 8, 2116 9 of 22
J. Clin. Med. 2019, 8, 2116 9 of 22

Figure 7. Computer-generated
Figure 7. Computer-generated3D 3Dsurgical-occlusion
surgical-occlusion splint
splint using
using surgery-first
surgery-first approach
approach based
based on
on final
final occlusion setup. Dental images displayed in Figures 2, 3,
occlusion setup. Dental images displayed in Figures 2, 3, 5 and 6.5 and 6.

2.5. Type of Orthognathic Approach

The cleft
cleft cohort
cohorthad
had23 23(52%)
(52%)and
and2121
(48%) patients
(48%) who
patients whounderwent conventional
underwent orthodontics-first
conventional orthodontics-
and surgery-first
first approaches,
and surgery-first respectively.
approaches, Eight (38%)
respectively. Eight and 13 (62%)
(38%) and 13patients
(62%) received
patients the standard
received the
and modified surgery-first models, respectively.
standard and modified surgery-first models, respectively.
The noncleft cohort had 4 (18%) and 18 (82%) (82%) patients
patients who underwent the conventional
orthodontics-first and surgery-first approaches, respectively.
respectively. Eleven (61%) and seven (39%) patients
received the standard and modified
modified surgery-first
surgery-first models,
models, respectively.
respectively.

2.6. Surgical
2.6. Surgical Approach
Approach
All the
All theincluded
included patients
patientsreceived 3D computer-assisted
received 3D computer-assisted single-splint two-jaw
single-splint orthognathic
two-jaw surgery
orthognathic
(final
surgeryocclusal
(final splint,
occlusal1-piece
splint,Le1-piece
Fort 1 Le
maxillary
Fort 1 osteotomy, and bilateral
maxillary osteotomy, andsagittal splitsagittal
bilateral osteotomy)
split
according to the previously described by our team [38–40]. Using the 3D simulated
osteotomy) according to the previously described by our team [38–40]. Using the 3D simulated image image as a guiding
template
as (Figure
a guiding 8), the(Figure
template maxillomandibular complex with 3D-printed
8), the maxillomandibular complex with final3D-printed
surgical-occlusion splint
final surgical-
was movedsplint
occlusion to thewas
desired
movedposition
to the(Figure
desired9).position
The Le Fort I was9).initially
(Figure The LefixedFort by using
I was 2-mm titanium
initially fixed by
miniplates placed on the nasomaxillary and zygomatico-maxillary
using 2-mm titanium miniplates placed on the nasomaxillary and zygomatico-maxillary pillars bilaterally, with nopillars
rigid
fixation in the
bilaterally, with anterior maxillary
no rigid fixationwalls.
in theThree-hole miniplates
anterior maxillary and Three-hole
walls. 6 mm screws were routinely
miniplates and 6 bent
mm
to match the maxillary contour at the Le Fort I osteotomy line, ensuring the
screws were routinely bent to match the maxillary contour at the Le Fort I osteotomy line, ensuring desired position of the
maxillomandibular complex. Longer miniplates, i.e., four or five holes, were
the desired position of the maxillomandibular complex. Longer miniplates, i.e., four or five holes,alternatively employed to
overcome
were potential employed
alternatively drawbacks to related to the potential
overcome presence of weak maxillary
drawbacks relatedboneto theor osteotomy-induced
presence of weak
maxillary bone or osteotomy-induced fracture in the medial or lateral maxillary pillarthe
fracture in the medial or lateral maxillary pillar region [39]. After Le Fort I fixation, proximal
region [39].
ramus segment was placed in a relaxed position and gently pushed up to
After Le Fort I fixation, the proximal ramus segment was placed in a relaxed position and gently ensure the position of the
condylarup
pushed head in the the
to ensure glenoid fossa.
position Percutaneous
of the condylar head insertion
in theofglenoid
three bicortical screws 14–16
fossa. Percutaneous mm long
insertion of
was performed in the ramus. No interpositional bone graft was used.
three bicortical screws 14–16 mm long was performed in the ramus. No interpositional bone graft Intermaxillary fixation was
released
was used.and the occlusionfixation
Intermaxillary was evaluated. Genioplasty
was released and thewas finally was
occlusion executed as planned,
evaluated. along with
Genioplasty was
intraoperative judgement. The patients with no intermaxillary
finally executed as planned, along with intraoperative judgement. The patients with nofixation were admitted in regular
intermaxillary fixation were admitted in regular ward for two days following the surgery and then
J. Clin. Med. 2019, 8, 2116 10 of 22

J. Clin. Med. 2019, 8, 2116 10 of 22

ward for two days following the surgery and then clinically examined based on regular surgical and
orthodontic appointments.
clinically examined based Aonliquid diet surgical
regular was recommended in the first
and orthodontic week, followed
appointments. by a soft
A liquid diet
diet wasin
the second week.
recommended in the first week, followed by a soft diet in the second week.

Figure 8.
Figure 8. 3D
3D imaging
imaging views
views displaying
displaying the
the measurements
measurements in medial and
in medial and lateral
lateral maxillary
maxillary pillars
pillars
bilaterally which are adopted as guiding template for transferring the 3D planning to actual single-
bilaterally which are adopted as guiding template for transferring the 3D planning to actual single-splint
splint technique-based
technique-based surgical
surgical procedure
procedure (Figure(Figure 9), including
9), including (Top) advancement
(Top) advancement in the antero-
in the antero-posterior
posterior direction,
direction, yaw(Bottom)
yaw rotation, rotation, vertical
(Bottom) vertical extrusion,
extrusion, and roll rotation.
and roll rotation.
J. Clin. Med. 2019, 8, 2116 11 of 22

J. Clin. Med. 2019, 8, 2116 11 of 22

Figure 9. Single-splint two-jaw orthognathic surgery principle. Both maxilla (Le Fort I segment) and
Figure 9. Single-splint two-jaw orthognathic surgery principle. Both maxilla (Le Fort I segment) and
mandible (two proximal ramus segments and one distal segment) were completely osteotomized,
mandible (two proximal
fixed in the ramus segments
final occlusion and onefinal
using the 3D-printed distal segment)
surgical-occlusion were
splint, completely
and moved as an osteotomized,
fixed in the final integrated
occlusion maxillomandibular complex to the 3D-simulated position. To transfer the 3D planning to
using the 3D-printed final surgical-occlusion splint, and moved as an
actual surgery, measurements in maxillary pillars bilaterally (Figure 8), face bow-based midline
integrated maxillomandibular
checking (nasal dorsum complex tomaxilla,
and tip, lips, the 3D-simulated position.
dental arches, and chin To transfer
areas), and middle and lower the 3D planning
facial third proportions judgments were used as reference. For this, the maxillomandibular complex
to actual surgery,was measurements in maxillary pillars bilaterally (Figure 8), face bow-based midline
moved in six potential directions, including pitch, roll, and yaw rotations (blue arrows) and en-
checking (nasal dorsum
bloc linear and tip,(left
horizontal lips, maxilla,
or right dental
shifts and arches,
advancements or and chin
setbacks areas),
in the and middle and lower
antero-posterior
direction) and vertical (extrusion or intrusion) movements (green arrows).
facial third proportions judgments were used as reference. For this, the maxillomandibular complex
was moved in 2.7.
six 3D
potential
Quantitative directions,
Analysis including pitch, roll, and yaw rotations (blue arrows) and en-bloc
linear horizontal (left
The 3Dor right
image shiftsdisplaying
datasets and advancements or setbacks
the final surgical-occlusion in the antero-posterior
setup adopted for surgery were direction)
included for analysis as they represented the occlusion setup in the context of surgical feasibility. 3D
and vertical (extrusion or intrusion) movements (green arrows).
quantitative analyses of occlusion characteristics were performed based on dentoskeletofacial
parameters defined in a previous investigation [32]: dental-occlusion contacts (number and location),
2.7. 3D Quantitative Analysis
overjet/overbite,angle molar relation (Class I, II, or III), posterior open bite, transverse arch
coordination, dental inclination, midline and transverse discrepancies, and jaw relationship (ANB
The 3D image datasets
angle displaying the
and A-point–nasion–B-point final
angle). All 3Dsurgical-occlusion
image datasets were analyzed setup
by anadopted
investigator for surgery were
with no information about the type of orthodontic approach by using Dolphin software tools (line,
included for analysis as occlusogram
angle, and they represented the Twenty
with a color map). occlusion
randomly setup
selectedin the context
patients’ CBCT scansof surgical feasibility.
were
measured in duplicate,
3D quantitative analyses with one-month
of occlusion interval betweenwere
characteristics each measurement.
performed based on dentoskeletofacial
Accuracy of surgical occlusion was determined by assessing the number of occlusions requiring
parameters defined
twoin a previous
setups [32]. The 3Dinvestigation [32]: dental-occlusion
CBCT-derived cephalometric normative data for thecontacts (number and location),
Taiwanese Chinese
overjet/overbite, angle molar relation (Class I, II, or III), posterior open bite, transverse arch coordination,
dental inclination, midline and transverse discrepancies, and jaw relationship (ANB angle and
A-point–nasion–B-point angle). All 3D image datasets were analyzed by an investigator with no
information about the type of orthodontic approach by using Dolphin software tools (line, angle, and
occlusogram with a color map). Twenty randomly selected patients’ CBCT scans were measured in
duplicate, with one-month interval between each measurement.
Accuracy of surgical occlusion was determined by assessing the number of occlusions requiring
two setups [32]. The 3D CBCT-derived cephalometric normative data for the Taiwanese Chinese
population were adopted as the reference value of the jaw relationship (ANB angle = 3.3 ± 1.6 (0.5–6.2)
degrees [44]).

2.8. Statistical Analysis

In descriptive analysis, data were presented as means ± standard deviations. It was verified that
the data were normally distributed by using the Kolmogorov–Smirnov test. The Student t-test and
chi-square test were used for the comparative analyses. Two-sided values of p < 0.05 were considered
statistically significant. All analyses were performed using SPSS Version 17.0 (IBM Corp., Armonk,
NY, USA).
J. Clin. Med. 2019, 8, 2116 12 of 22

3. Results
No new surgical-occlusion setup was required during virtual planning. All patients were treated
by two-jaw orthognathic surgery, with no intraoperative problems with the 3D-printed final-occlusion
splints. On average, a normal jaw relationship was noticed after virtual planning in the cleft and
noncleft cohorts (ANB angle = 3.4 and 3.2 degrees, respectively; p > 0.05). Three patients with cleft and
one patient with noncleft presented with lip or chin numbness at 1–6 months postoperatively, with
full recovery at long-term evaluations. No wound infection, postoperative hemorrhage/hematoma,
or requirement or request for revisionary surgery during follow-up was observed in the cleft and
noncleft cohorts.

3.1. Time of Presurgical Orthodontic Therapy

The time for presurgical orthodontic therapy was similar between cohorts, with 11.7 ± 3.8 and
10.2 ± 7.4 (p = 0.447) months in the conventional orthodontics-first approach, and 4.9 ± 1.6 and 4.0 ± 1.0
(p = 0.171) months in the modified surgery-first model for the cleft and noncleft cohorts, respectively.
Patients who underwent the standard surgery-first model had no presurgical orthodontic therapy.

3.2. Primary Endpoint

No significant difference was observed in comparison between standard and modified surgery-first
models for all parameters (Table 2).

Table 2. Comparison of surgical occlusions between standard surgery-first and modified surgery-first
models in cleft cohort.

Standard Surgery-First Model Modified Surgery-First Model

Parameters p-Value
(n = 8) (n = 13)
Dental-occlusion contacts
Number of segmental contacts * n (%)
Three segments 6 (66.7%) 11 (84.6%)
Two segments 2 (33.3%) 1 (7.7%) 0.425
One segment 0 (0%) 1 (7.7%)
Number of tooth contacts m ± sd
Anterior teeth 1.88 ± 0.99 1.69 ± 1.03 0.694
Premolar teeth 2.88 ± 0.83 2.15 ± 2.88 0.139
Molar teeth 2.00 ± 1.41 2.92 ± 1.26 0.135
Total 6.75 ± 1.28 6.77 ± 2.05 0.981
Incisor midpoint relation (mm) m ± sd
Overjet 3.70 ± 2.26 3.07 ± 1.27 0.420
Overbite 1.27 ± 0.90 1.02 ± 0.98 0.574
Midline deviation (mm) m ± sd
Upper midline deviation 0.48 ± 0.53 1.10 ± 1.42 0.254
Midline discrepancy 1.36 ± 1.69 1.10 ± 0.93 0.687
Pogonion deviation 1.37 ± 1.06 1.61 ± 1.46 0.652
Transverse discrepancy (mm) m ± sd
Maxillary intercanine distance 29.70 ± 5.70 29.00 ± 6.45 0.804
Maxillary intermolar distance 49.93 ± 7.40 49.57 ± 4.05 0.888
Mandibular intercanine distance 28.85 ± 2.37 26.54 ± 2.60 0.055
Mandibular intermolar distance 47.55 ± 4.49 46.95 ± 2.54 0.700
Ratio of intercanine distance 1.03 ± 0.22 1.10 ± 0.23 0.535
Ratio of intermolar distance 1.05 ± 0.10 1.06 ± 0.11 0.791
Canine lateral overjet discrepancy 5.97 ± 3.89 4.30 ± 3.00 0.283
First molar lateral overjet discrepancy 3.10 ±1.94 2.24 ± 1.28 0.234
Skeletal discrepancy m ± sd
ANB (◦ ) 3.00 ± 3.90 3.12 ± 3.29 0.937
Advancement of A-point (mm) 3.90 ± 1.53 5.68 ± 2.20 0.059
Setback of B-point (mm) −4.78 ± 3.59 −5.93 ± 5.01 0.578
n, number of patients; m, mean; sd, standard deviation; mm, millimeters; o , degree; ANB, A-point–nasion–B-point
angle; A point, point of maximum concavity in midline of alveolar process of maxilla; B point, point of maximum
concavity in midline of alveolar process of mandible; *, maxillary arch divided into three segments: anterior,
posterior right, and posterior left.
J. Clin. Med. 2019, 8, 2116 13 of 22

There were significant (all p < 0.05) differences in the comparison between surgery-first and
conventional orthodontics-first approaches in the number of anterior-tooth contacts and incisor overjet
parameters, with no significant difference for the remainder of the tested parameters (Table 3).

Table 3. Comparison of surgical occlusions between the surgery-first and conventional approaches in
cleft cohort.

Surgery-First Approach Conventional Approach

Parameters p-Value
(n = 21) (n = 23)
Dental occlusion contacts
Number of segmental contacts * n (%)
Three segments 17 (81.0) 18 (78.3)
Two segments 3 (14.3) 3 (13.0) 0.873
One segment 1 (4.7) 2 (8.7)
Number of teeth contacts m ± sd
Anterior teeth 1.76 ± 1.00 2.52 ± 1.38 0.044
Premolar teeth 2.42 ± 1.08 2.57 ± 1.04 0.670
Molar teeth 2.57 ± 1.36 2.04 ± 1.26 0.189
Total 6.76 ± 1.76 7.13 ± 2.30 0.557
Incisor midpoint relation (mm) m ± sd
Overjet 3.31 ± 1.69 2.12 ± 1.26 0.011
Overbite 1.11 ± 0.93 0.51 ± 1.25 0.077
Midline deviation (mm) m ± sd
Upper midline deviation 0.86 ± 1.18 0.83 ± 1.03 0.923
Midline discrepancy 1.21 ± 1.43 1.02 ± 1.18 0.634
Pogonion deviation 1.52 ± 1.30 1.44 ± 1.01 0.826
Transverse discrepancy (mm) m ± sd
Maxillary intercanine distance 29.27 ± 6.04 30.50 ± 5.60 0.485
Maxillary intermolar distance 49.70 ± 5.39 50.10 ± 3.69 0.774
Mandibular intercanine distance 27.42 ± 2.71 27.73 ± 1.31 0.625
Mandibular intermolar distance 47.18 ± 3.32 46.77 ± 3.39 0.687
Ratio of intercanine distance 1.07 ± 0.22 1.10 ± 0.22 0.646
Ratio of intermolar distance 1.06 ± 0.11 1.08 ± 0.09 0.515
Canine lateral overjet discrepancy 4.94 ± 3.37 3.60 ± 2.65 0.149
First molar lateral overjet discrepancy 2.57 ± 1.58 1.78 ± 1.34 0.080
Skeletal discrepancy m ± sd
ANB (o ) 3.41 ± 3.55 2.54 ± 2.32 0.337
Advancement of A-point (mm) 5.00 ± 2.12 5.00 ± 1.84 0.997
Setback of B-point (mm) 5.49 ± 4.46 6.06 ± 5.06 0.698
n, number of patients; m, mean; sd, standard deviation; mm, millimeters; o , degree; ANB, A-point–nasion–B-point
angle; A point, point of maximum concavity in midline of alveolar process of maxilla; B point, point of maximum
concavity in midline of alveolar process of mandible; *, maxillary arch divided into three segments: anterior,
posterior right, and posterior left.

Comparative analyses considering the cleft side revealed significantly (all p < 0.05) larger
(interincisal angle, U1 overjet, and presence of posterior open-bite parameters) and smaller (number of
anterior-tooth contacts and U1 inclination parameters) values for the surgery-first and conventional
approaches, respectively. Considering the noncleft side, the surgery-first approach had significantly
(all p < 0.05) larger (interincisal angle, U1 overjet, and presence of posterior open-bite parameters)
values than conventional approach (Table 4).
J. Clin. Med. 2019, 8, 2116 14 of 22

Table 4. Comparison of surgery-first and conventional approaches in cleft cohort.

Cleft Side Noncleft Side

Surgery-First Conventional Surgery-First Conventional
Parameters Approach Approach p-Value Approach Approach p-Value
(n = 21) (n = 23) (n = 21) (n = 23)
Dental occlusion contact
Angle classification n (%)
Angle Class I 2 (9.6) 1 (4.3) 1 (4.8) 4 (17.4)
Angle Class II 19 (90.4) 22 (95.7) 0.496 19 (90.4) 19 (82.6) 0.257
Angle Class III 0 (0) 0 (0) 1 (4.8) 0 (0)
Number of tooth contact m ± sd
Anterior teeth 0.76 ± 0.70 1.22 ± 0.67 0.033 1.00 ± 0.55 1.30 ± 1.11 0.249
Premolar teeth 1.24 ± 0.62 1.35 ± 0.65 0.571 1.19 ± 0.68 1.22 ± 0.67 0.896
Molar teeth 1.24 ± 0.89 1.00 ± 0.74 0.338 1.33 ± 0.86 1.04 ± 0.82 0.259
Total 3.24 ± 1.14 3.57 ± 1.34 0.390 3.52 ± 1.17 3.57 ± 1.41 0.916
Dental inclination (o ) m ± sd
U1 inclination 98.37 ± 14.27 105.96 ± 9.73 0.044 101.72 ± 9.54 106.61 ± 8.13 0.074
Interincisal angle 135.20 ± 15.22 123.38 ± 12.64 0.007 130.64 ± 12.25 122.96 ± 11.36 0.037
Anteroposterior relation (mm) m ± sd
U1 overjet 3.24 ± 2.12 1.82 ± 1.27 0.009 3.39 ± 1.43 2.42 ± 1.44 0.030
U6 overjet 6.41 ± 3.85 7.16 ± 5.73 0.609 3.65 ± 4.27 4.29 ± 4.43 0.628
Vertical relation of teeth
U1 overbite (mm) m ± sd 0.80 ± 1.18 0.24 ± 1.31 0.144 1.43 ± 0.88 0.77 ± 1.29 0.057
Posterior open bite (U7) n (%)
Yes 11 (52.4) 6 (26.1) 13 (61.9) 7 (30.4)
0.041 0.035
No 10 (47.6) 17 (73.9) 8 (38.1) 16 (69.6)
Transverse arch coordination m ± sd
Midline to U3 distance (mm) 12.66 ± 3.41 14.02 ± 3.15 0.177 16.19 ± 3.57 16.18 ± 3.25 0.996
Midline to L3 distance (mm) 13.74 ± 2.89 14.03 ± 1.40 0.667 13.61 ± 2.62 13.89 ± 3.10 0.749
Midline to canine ratio 0.95 ± 0.29 1.02 ± 0.29 0.470 1.20 ± 0.24 1.17 ± 0.25 0.640
Canine lateral overjet (mm) −1.08 ± 3.79 −0.01 ± 3.97 0.368 2.58 ± 2.94 2.29 ± 3.84 0.785
Midline to U6 distance (mm) 25.08 ± 2.97 24.89 ± 2.48 0.811 24.96 ± 3.73 25.18 ± 2.27 0.813
Midline to L6 distance (mm) 23.57 ± 2.88 23.49 ± 2.31 0.918 23.05 ± 2.27 23.11 ± 2.36 0.933
Midline to first molar ratio 1.07 ± 0.12 1.06 ± 0.11 0.838 1.08 ± 0.14 1.10 ± 0.09 0.749
First molar lateral overjet 1.52 ± 2.82 1.40 ± 2.43 0.883 1.91 ± 3.16 2.07±1.98 0.838
Maxillary occlusion angle (o )
−9.08 ± 7.27 −11.79 ± 3.91 0.139 −10.45 ± 5.51 −10.99 ± 4.65 0.726
m ± sd
Jaw movement (mm) m ± sd
Advancement of U3 4.12 ± 2.98 4.45 ± 2.54 0.698 3.49 ± 3.29 2.87 ± 2.20 0.467
Impaction of U3 0.99 ± 2.40 0.50 ± 1.68 0.436 0.32 ± 2.02 0.22 ± 2.02 0.872
Advancement of U6 4.43 ± 3.07 5.08 ± 3.08 0.492 3.34 ± 3.09 2.37 ± 2.73 0.277
Impaction of U6 −0.50 ± 1.31 −0.49 ± 1.67 0.980 −1.05 ± 1.70 −1.12 ± 2.35 0.910
Setback of mandible −4.35 ± 4.73 −4.90 ± 5.40 0.722 −4.64 ± 4.18 −6.24 ± 3.97 0.199
U1, upper central incisor; U3, upper canine; L3, lower canine; U6, upper first molar; L6, lower first molar; U7, upper
second molar.

3.3. Secondary Endpoint

Considering the surgery-first approach, the cleft cohort presented significantly (all p < 0.05) larger
(canine lateral overjet parameter) and smaller (incisor overjet, maxillary intercanine distance, maxillary
intermolar distance, ratio of intercanine distance, and ratio of intermolar distance parameters) values
than the noncleft cohort (Table 5).
J. Clin. Med. 2019, 8, 2116 15 of 22

Table 5. Comparison of cleft and noncleft cohorts.

Cleft Cohort Noncleft Cohort

Parameters p-Value
(n = 21) (n = 18)
Dental-occlusion contact
Number of segmental contacts * n (%)
Three segments 17 (81.0) 15 (83.3)
Two segments 3 (14.3) 3 (16.7) 0.638
One segment 1 (4.7) 0 (0)
Number of teeth contacts m ± sd
Anterior teeth 1.76 ± 1.00 2.50 ± 1.38 0.061
Premolar teeth 2.42 ± 1.08 2.22 ± 1.44 0.612
Molar teeth 2.57 ± 1.36 2.72 ± 1.18 0.716
Total 6.76 ± 1.76 7.44 ± 2.23 0.292
Incisor midpoint relation (mm) m ± sd
Overjet 3.31 ± 1.69 4.37 ± 1.27 0.036
Overbite 1.11 ± 0.93 1.46 ± 1.62 0.432
Midline deviation (mm) m ± sd
Upper midline deviation 0.86 ± 1.18 0.55 ± 0.42 0.287
Midline discrepancy 1.21 ± 1.43 0.54 ± 0.67 0.063
Pogonion deviation 1.52 ± 1.30 1.38 ± 1.46 0.749
Transverse discrepancy (mm) m ± sd
Maxillary intercanine distance 29.27 ± 6.04 36.04 ± 2.67 <0.001
Maxillary intermolar distance 49.70 ± 5.39 54.61 ± 3.55 0.002
Mandibular intercanine distance 27.42 ± 2.71 27.12 ± 3.33 0.756
Mandibular intermolar distance 47.18 ± 3.32 47.31 ± 3.05 0.900
Ratio of intercanine distance 1.07 ± 0.22 1.34 ± 0.16 <0.001
Ratio of intermolar distance 1.06 ± 0.11 1.16 ± 0.10 0.004
Canine lateral overjet 4.94 ± 3.37 1.37 ± 1.35 <0.001
First molar lateral overjet 2.57 ± 1.58 2.30 ± 1.84 0.626
Skeletal discrepancy m ± sd
ANB (o ) 3.41 ± 3.55 3.28 ±1.19 0.882
Advancement of A-point (mm) 5.00 ± 2.12 3.86 ± 1.52 0.066
Setback of B-point (mm) −5.49 ± 4.46 −6.23 ± 3.34 0.567
n, number of patients; m, mean; sd, standard deviation; mm, millimeters; o , degree; ANB, A-point–nasion–B-point
angle; A point, point of maximum concavity in midline of alveolar process of maxilla; B point, point of maximum
concavity in midline of alveolar process of mandible; *, maxillary arch divided into three segments: anterior,
posterior right, and posterior left.

3.4. Reliability
Intra-investigator reliability was considered excellent (intraclass correlation coefficients = 0.898 to
0.975) for all quantitative parameters.

4. Discussion
In this comparative study of occlusion setup, the primary endpoint-related data releveled a smaller
number of anterior teeth contacts and larger incisor overjet in the surgery-first cleft-orthognathic surgery
approach than the conventional cleft-orthognathic surgery approach, which clinically represents an
incisor decompensation postponed after surgery. Patients with cleft also had smaller overjet and higher
anterior contacts in cleft side with conventional orthognathic surgery than surgery first approach,
which characterizes the typical status of dentition in surgery first-treated patients who had the upper
incisors positioned in a more upright position due to surgical procedure-derived scar contraction.
Moreover, the secondary endpoint-related data demonstrated a larger canine lateral overjet and smaller
incisor overjet and maxillary transversal-related distances in the surgery-first cleft-orthognathic surgery
J. Clin. Med. 2019, 8, 2116 16 of 22

approach than surgery-first noncleft-orthognathic surgery approach, which clinically represents the
cleft-associated dental anomalies and transverse maxillary collapse.
The optimal balance between esthetic and functional outcomes, significant reduction in
total treatment time, and high rates of patient satisfaction have led to the postulation that the
modern surgery-first orthognathic-approach concept may denote a reasonable and cost-effective
pathway to manage dentoskeletofacial deformities, and has the potential to become the first-line
orthognathic-surgery intervention in the future [18–20]. Despite published recommendation for
selection of patients for the surgery-first approach [22,23], there are no unique criteria adopted by
different centers and clinicians [15–20,24,27–31,45–53]. While some patterns of presentation (e.g., Class
III prognathism with open bite) have been considered as good candidates for the surgery-first approach,
a wide spectrum of dental configurations have also been contemplated for surgery-first orthognathic
surgery treatment [15–20,22–24,27–31,45–53]. However, patients with cleft-skeletofacial deformities
have not been considered as potential candidates to receive this therapeutic modality [24]. This modern
approach can theoretically have enhanced influence on patients with clefts who had an extensive
dental and orthodontic burden of care since infancy [54]. Due to the prevalence of clefts and the global
number of patients requiring orthognathic treatment [1–4], it is reasonable for this therapeutic option
to be considered and investigated.
It is important to emphasize that the surgical-occlusion setup is certainly more technically
demanding in cleft than non-cleft deformities due to the complex cleft-related dental abnormalities,
such as irregular arch form and shape as well as teeth anomalies [11,55,56]. In the conventional
orthodontics-first approach, as presurgical therapy brings maxillary and mandibular teeth into ideal
relationships to the underlying skeletal bases, the surgical-occlusion setup is very close to the final
occlusion, i.e., the ideal occlusion [11–13]. When embracing the surgery-first approach, dental alignment,
arch leveling, and coordination, and incisor decompensation are deferred for postsurgical management;
the surgical-occlusion setup is consequently different from the final (ideal) occlusion at the end of
treatment [22,23,28]. Not only can anteroposterior dental movements be orthodontically adjusted
postoperatively, but also transverse and vertical dental movements can be successfully achieved due to
the increased metabolic turnover of the regional acceleratory phenomenon [36]. Surgical occlusion in
surgery-first treatment was thus set as a treatable malocclusion [22,23,28]. A major concern for this
setup is the accurate estimation of the required space for postsurgical dental movement with many
combinations of potential directions [22,23,28]. These challenges are probably the major hampering
factors for the widespread use of this technique in cleft centers globally.
In this center, the indication of surgery-first orthognathic surgery treatment has been
variable [22,23,57–59]. In our orthognathic surgery workflow, the combination of accurate clinical
examinations and high-quality 3D imaging has permitted a precise preoperative diagnosis that
encompasses the many deviations of involvement of the dental, skeletal, and facial soft tissue elements,
with less favorable patterns of dental characteristics being not considered contraindication for the
surgery-first approach. The rate of indication of this surgery-first protocol has mainly been determined
by level of orthodontic experiences to evaluate the accomplishment of a workable surgical-occlusion
setup and to anticipate an achievable postoperative orthodontic treatment planning [22,23,57–59], with
senior experienced professionals (not included as co-authors of this current study) reaching a rate of
100% for surgery-first-based treatments [59]. Therefore, due to the accumulated experience of our team
with a high-volume of surgery-first noncleft orthognathic-surgery procedures [22,23,28,32–37], the
surgery-first approach has progressively been adopted for cleft-skeletofacial deformity. The regular
use of virtual simulation has also assisted the change of our cleft practice, as CBCT-derived images
allow three-dimensionally appraising the precision of the surgical-occlusion setup in terms of residual
or induced skeletal deformity with a designation of surgical feasibility before the actual procedure [40].
For the surgery-first approach, we have indicated the surgical procedure in patients with no need for
presurgical therapy or requiring a short period of therapy (standard and modified models, respectively).
Other proponents of the surgery-first approach have also adapted models for a short preparatory phase
J. Clin. Med. 2019, 8, 2116 17 of 22

(e.g., “minimal” and “early”), with presurgical therapy ranging 1–6 months, and the preservation of
key advantages of the surgery-first pathway (i.e., immediate postoperative improvement of facial
appearance with substantial reduction of total treatment time) [45–51]. In the current study, no
differences were found between the cleft and noncleft cohorts for presurgical-therapy time in the
modified surgery-first model. Moreover, no need for revisionary surgery was observed during
follow-up. These aspects reveal that it is clinically feasible to apply the principles of selection of patient
dentition in the cleft scenario with achievement of the desired surgical-occlusion setup, but with no
compromise of time and surgical achievability parameters.
As expected, the standard and modified surgery-first models had no significant difference for all
tested parameters, reinforcing that the same principles were adopted during the surgical-occlusion
setup of the surgery-first approach regardless of a short period of presurgical orthodontic therapy.
Logically, patients managed with the modified model had slight differences in dentition status at
presentation in our center compared to patients managed by the standard model. Importantly, the main
target of the modified surgery-first treatment was not to transform a patient’s dentition with indication
for conventional orthodontics-first approach into a favorable dentition to receive a surgery-first
approach. Presurgical orthodontics was actually only applied to reduce potential premature contact
between maxillary and mandible teeth with the removal of severe occlusal interference enhancing
stable surgical occlusion. Minimal decompression of mandibular teeth was also performed when
necessary, but with no attempt for decompression of the maxillary teeth.
Different strategies have been employed during surgical-occlusion setup to compensate
for space for dental alignment, and arch leveling and coordination after surgery, but with no
consensus among advocates of the surgery-first approach and no quantitative data for cleft-related
treatment [22,23,27–38]. Appraisal of comparative analyses of this study reveals 3D quantitative-based
practical fundamentals for surgical-occlusion setup in surgery-first cleft-orthognathic surgery. In the
conventional orthodontics-first approach, surgical occlusion was ideally set as a normal overjet
(2 mm) and overbite (2 mm) and Class I molar relationship [60]. Because compensation of horizontal
mandibular relapse was planned for with a 2 mm overcorrection in surgery-first treatment [28,32],
the Class II molar relationship was frequently set in the occlusion of both cleft and noncleft sides.
As incisor decompensation was deferred after surgery [28,32], analyses of the cleft cohort exhibited a
significantly larger overjet in the surgery-first than the conventional approach. However, the noncleft
cohort (mean of 4.37 mm) had a significantly larger overjet than the cleft cohort (mean of 3.31 mm).
This is not surprising because the upper incisors of patients with clefts are positioned in a more upright
position due to scar contracture from previous surgical interventions [11,55,56].
Definitions of stable occlusion were previously described [15,16,27,30]. To achieve proper tooth
contacts with at least three-point teeth contact (preferably one and two at the anterior and bilateral
posterior regions, respectively), increasing the posterior open bite by pitch counterclockwise rotation
of the distal mandibular segment was formerly recommended [28]. This compromise of superoinferior
dental position in the posterior region to attain a better setup in the anterior region was adopted in
our cohorts in a case-by-case basis, with the posterior open bite respecting the limit of postoperative
orthodontic tooth movement (<10 mm) [22,23,28,32]. Based on the current quantitative data, stable
occlusion can be achieved by occlusal contact on one (anterior region), two, or three (most frequent
pattern in both cleft and noncleft cohorts) segments or occlusal contact on five to seven teeth, with
all of the included patients presenting with at least one point of contact in the anterior maxillary
segment. This quantitative pattern of surgical-occlusion setup is similar to a previous report showing
quantitative data in noncleft Class III skeletal deformity [28], suggesting that it is possible to achieve
stable occlusion even in patients with clefts and associated dental anomalies.
It was advised to not include posterior crossbite at setup [27,31], but our strategies in the transverse
dimension emphasized the coordination of jaw midlines instead of the dental arch to avoid positional
jaw asymmetry [28]. Current data show that the cleft cohort had significantly smaller values for
maxillary transversal-related distances than the noncleft cohort, but with no difference for the mandible
J. Clin. Med. 2019, 8, 2116 18 of 22

region. Transversal deficiencies secondary to scar-tissue contraction are one of the major concerns for
professionals treating patients with clefts [61–63]. In our center, the rate of maxillary segmental surgery
to correct maxillary transversal-related issues has decreased over the years, as selection of patients for
each type of procedure, and the technical details have accordingly evolved. Segmental surgery has only
been indicated in patients with severe skeletal crossbite. Arch coordination is deferred after surgery
with the surgery-first approach, with posterior dental crossbite and mild skeletal crossbite being
orthodontically corrected, for example, by bending orthodontic archwire, or inter- or intra-arch elastics.
The potential limitations of this study should be addressed. Due to the adopted study design, we
do not provide inter-investigator reliability for quantitative analysis and intra- and inter-professional
reliability for occlusion setup, deserving future investigation by using a distinct methodological
approach [64,65]. Our results are restricted to a relatively limited number of patients. An a priori
sample size and power calculation could not be defined due to the methodological heterogeneity
between the current study and prior literature. We also do not provide post-hoc power analysis due
to the inadequacy of this particular method [66,67]. In addition, our findings are based on a specific
subgroup of young adult patients with unilateral complete cleft lip/palate who were managed by
the same orthodontic and surgeon professionals by using two types of orthodontic approaches and
a particular surgical technique (3D-assisted single-splint two-jaw procedure). Moreover, patients
with variable degree of the dental presentation (curve of Spee, anterior-teeth alignment, incisor
inclination, and present dentition) were included in this study. This represents the orthognathic
surgery practice in this center and further details of the patient-specific approach have previously
been described [22,23,28,32–37,39,57–59]. This study presented 3D quantitative data derived from the
final surgical-occlusion setups of patients who actually received orthognathic treatment and presented
no need for revision procedure during follow-up, which denoted satisfactory results. As the patient
cohorts were not selected based on surgical results (satisfactory or unsatisfactory), the bias related to
analyses performed only on the satisfactory results was considerably reduced, which infers therapeutic
feasibility in the cohorts reported here. Moreover, as the applied surgical-orthodontic treatment would
considerably vary depending on the dentition status of each patient, orthodontists and surgeons
should be aware of the principles and limits of the surgery-first approach during the definition of
patient-specific diagnosis and the therapeutic plan (including the prediction of postsurgical change).
However, this study does not provide postoperative stability-related statistics, long-term follow up data
on results, or information that may guide postoperative arch coordination and dental decompensation,
deserving further investigation.
This study did not answer all issues about the addressed topic; however, the current 3D quantitative
data can be adopted and adapted by other multidisciplinary teams as initial benchmark values for
surgical-occlusion setup in surgery-first cleft-orthognathic surgery. The indication barriers for the
surgery-first approach are continuously changing, and we expect that a higher number of patients
with clefts would benefit from this modern approach in the future. This may result in changes of the
current delivery of cleft-orthognathic surgery care.

5. Conclusions
This comparative study of occlusion setup showed: (1) similar 3D quantitative characteristics in
standard and modified surgery-first models for the cleft cohort; (2) a smaller number of anterior teeth
contacts and larger incisor overjet in the surgery-first cleft-orthognathic surgery approach than the
conventional cleft-orthognathic surgery approach; and (3) a larger canine lateral overjet and smaller
incisor overjet and maxillary transversal-related distances in the surgery-first cleft-orthognathic surgery
approach than surgery-first noncleft-orthognathic surgery approach.

Author Contributions: Conception and design, H.J.S., R.D., B.C.-J.P., and L.-J.L.; acquisition, analysis, and
interpretation of data, H.J.S., R.D., and B.C.-J.P.; drafting of the article, H.J.S. and R.D.; critical revision of the article,
B.C.-J.P. and L.-J.L.; study supervision, L.-J.L.; and review of the submitted version of the manuscript, all authors.
J. Clin. Med. 2019, 8, 2116 19 of 22

Funding: This study was supported by grants from the Ministry of Science and Technology (MOST
106-2314-B-182-027-MY2, MOST 108-2314-B-182-001, and MOST 108-2622-E-182-001-CC2) and the Chang Gung
Memorial Hospital (CMRPG5C0031-33).
Acknowledgments: We would like to thank our research assistants (Yi-Tan Hung and Lien-Shin Niu) who
provided help during data collection.
Conflicts of Interest: The authors declare no potential conflict of interest with respect to the authorship or
publication of this article.

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