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Chapter 10
Surgery First Approach
Ayşe Gülşen
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http://dx.doi.org/10.5772/intechopen.80951
Abstract
The surgery first approach (SFA) was presented by some researchers in earlier years, but
SFA in a combined treatment, with the surgery first and the orthodontic treatment second,
as introduced by Brachvogel et al. and by Nagasaka et al., has gained attention in the past
10 years. The advantages of SFA were reported in the literature, and the research into this
method continues. One of the advantages of the SFA is the shorter total treatment time,
and another is that patients begin treatment with a much improved face esthetically. The
protocol of presurgical orthodontics is well known in dentofacial anomalies, but in SFA,
especially in complex cases, the meticulous treatment is very important. In this chapter,
SFA will be discussed.
Keywords: surgery first, orthognathic surgery, orthodontics
1. Introduction
The treatment of skeletal discrepancies requires orthognathic surgery in combination with
orthodontic treatment to improve malocclusion, function, facial, and smile esthetics.
In the 1960s, the surgeons performed orthognathic surgery without orthodontic treatment [1–3].
But it was clearly understood that mandibular or maxillary movement was limited without
tooth movement. For example, amount of mandibular setback was limited by the overjet in
Class III cases. To achieve a proper setback and to have a good the occlusal and facial esthet-
ics results, orthodontic alignment of malaligned teeth and solving the compensation of teeth
to the malposed jaws are required before surgery [4–6]. After the 1970s, orthognathic sur-
gery in combination with orthodontic treatment began to have good standards and showed
popularity [7–11].
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
distribution, and reproduction in any medium, provided the original work is properly cited.
146 Current Approaches in Orthodontics
In conventional orthognathic surgery approach, the surgery follows the orthodontic treat-
ment (orthodontic-first approach). Teeth are tended to compensate for skeletal discrepan-
cies to have functional occlusion. The presurgical orthodontic treatment is needed to solve
the dental decompensation that reveals the true extent of the skeletal deformity to align
the teeth and to fit the maxilla and mandible into a good occlusion after surgery [11, 12].
Following the orthodontic treatment, orthognathic surgery corrects the skeletal discrepancy
to obtain a good jaw alignment with good facial proportions. As the direction of presur-
gical orthodontic treatment is opposite to that of natural dental compensation forces, the
orthodontic treatment time is said to require time to overcome the natural compensation
forces [13]. The presurgical orthodontic treatment period which includes aligning dental
occlusion, reversing incisor decompensation, correcting tooth rotation, and arch coordina-
tion lasts for 12–36 months depending on the complexity of case and also for a period after
the surgery [13].
In last 10 years, surgery first approach (SFA) has begun to be implemented in some centers
[14] and created broader interest [15–20].
The surgery first approach (SFA) is the orthognathic surgery approach that the orthognathic
surgery precedes the orthodontic treatment. In the beginning of the treatment, surgery is
performed without orthodontic preparation, and the orthodontic treatment is done after the
surgery.
Historically, the SFA was presented by some researchers in earlier years [2, 21–24], but SFA
in a combined treatment, which was introduced officially by Brachvogel et al. [25] and by
Nagasaka et al., has gained attention in the past 10 years [26].
Among the published studies about SFA regarding the type of malocclusion, Class III is the
most prevalent. Class III with openbite and asymmetry cases with SFA are the other pub-
lished studies. SFA in Class II cases and in some deformities like TMJ disorders or condylar
hyperplasia is rare [27–29].
2. The advantages of SFA
The advantages of SFA reported in literature continue. One of the advantages of the SFA is
the shorter total treatment time [13, 15, 30]. Other advantages are that patients begin treat-
ment with a much improved face esthetically in the beginning of the treatment and that the
patient’s chief complaint, dental function, and facial esthetics are achieved and improved in
the beginning of the treatment [31, 32] and a psychosocial benefit of improved body image
in the beginning of the treatment instead of worsening the facial appearance because of the
presurgical decompensation of incisors [31, 34]. Improved corporation of the patient during
the treatment may be the other advantage of SFA due to rapid profile improvement [33, 35].
SFA is also preferred in early correction of obstructive sleep apnea patients. On the other side,
due to the early correction of skeletal and soft tissue problems, orthodontic treatment may be
easier due to normalized surrounding soft tissue [23]. It was reported that the patients with
preexisting TMJ dysfunction might experience a significant improvement of TMD signs and
symptoms after SFA [29].
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One of the reasons for the shorter duration of treatment in SFA is the regional accelerated
phenomenon (RAP) which is the increase of the osteoclastic and metabolic activities due to
the surgery. Selective bone injury activates stimulus for anabolic and catabolic responses in
the periodontium adjacent to the osteotomies performed during orthognathic surgery and
increases bone reorganization [32, 36–45]. It was reported that RAP in humans began in a
few days after surgery and peaked at 1–2 months and took 6 months to more than 24 months
to subside [39]. Liou et al. also studied the causes of rapid postoperative orthodontic treat-
ment time in SFA cases, and they found that the levels of serum alkaline phosphatase and
C-terminal telopeptide of type I collagen (ICTP) increased, which supported the postopera-
tive accelerated orthodontic tooth movement caused the orthognathic surgery [15]. Zingler
et al. found that crevicular fluids in SFA cases were higher levels of bone remodeling factors
for fracture healing [32].
The other reason for the shorter duration of treatment in SFA than in the conventional
approach may be improvement of function. Choi and Bradley reported that teeth tended
Figure 1. a-d: Facial asymmetry case. Passive arch wires were inserted the day before surgery.
148 Current Approaches in Orthodontics
to move in the direction of decompensation to perform the function following the surgery
[46]. Postoperative orthodontic direction and function improve the efficiency of decompen-
sation. Additionally, orthodontic movement via a more rapid natural dental adaptation by
facilitating natural compensation may be performed easier with less occluded occlusion.
Orthodontic treatment time depends on the complexity of case. The shortest reported treat-
ment time is 4 months (Figure 1a-d, 2a-d) but generally it takes 6–12 months [17, 26, 28, 33, 35,
47–50]. Tooth extraction is the factor that influences the total treatment time [13], and in some
cases, the time range was reported between 10 and 19 months [51–53].
Figure 2. a-d: Three months later after surgery. Total treatment time 3 and half months.
Surgery First Approach 149
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3. Treatment plan in SFA
SFA is indicated more common in some cases like well-aligned to mildly crowded anterior
teeth, flat to mildly curve of Spee, and normal to mildly proclined/retroclined incisor inclina-
tion. The protocol of presurgical orthodontics is well known in conventional approach [4, 8];
however, treatment plan including orthodontic treatment is questioned in SFA especially in
complex cases. The orthodontic management and treatment plan are different in SFA com-
pared with the conventional approaches.
In treatment plan, accurate and detailed prediction of the postoperative orthodontic treat-
ment is required at the beginning of all treatment [50]. Following the analysis of occlusion
with model mounting, of detailed clinical and cephalometrics, presurgical orthodontic setup
that is useful for accurate prediction and simulation of postsurgical orthodontics and cepha-
lometric setup may be required before the surgery [13, 51].
The model surgery is a setup according to the cephalometric and molar relationship. Three
stable occlusion points between the upper and lower dentitions are required [38]. Liou et al.
reported that the molar relationship could be set up in Class I in cases of nonextraction or
bimaxillary first premolar extraction, Class III in cases of lower first premolar extraction, and
Class II in cases of maxillary first premolar extraction [16].
Following cephalometric, model, and clinical diagnosis, the aim is to optimize the position of
facial components to attain the most desirable results in esthetics, function, and stability. The
skeletal movements in all anteroposterior, vertical, and transverse directions are determined
to obtain good facial proportions, smile esthetics, and occlusion.
Liou et al. have made some suggestions in treatment plan of SFA [16]. In Class III cases, to
correct the decompensation of maxillary incisor, first premolar extraction and retraction of
anterior teeth can be done by orthodontics or by anterior segmental osteotomy. If the case has
moderately retroclined and crowded lower incisors, the molars in a Class I relationship with
an excessive incisor overjet can be planned. In cases with severe crowding and retroclination
in mandible, first premolar extraction and lower anterior setback osteotomy can be planned.
In Class III cases with deep curve of Spee, leveling of Spee can be corrected before the surgery
or can be corrected with lower anterior segmental osteotomy surgically to avoid upward-
forward rotation of mandible postoperatively, which is not preferred in Class III cases. The
chin cap therapy may be used to prevent the skeletal postsurgical relapse after surgery for 3
months [16]. In Class II cases, in mandibular retrognathia with deep curve of Spee, mandibu-
lar advancement with surgical intrusion of anterior segment to advance mandible properly or
mandibular advancement followed by orthodontically intrusion of lower incisor postsurgi-
cally is proposed to obtain a better chin profile. Otherwise, the mandible cannot be advanced
properly and lower face can be longer with correction of posterior openbite after surgery,
and this cannot be preferred in some long face case. But in some cases where advancements
are not required much, correction of posterior openbite only with posterior extrusion can be
preferred [54].
150 Current Approaches in Orthodontics
4. Time for orthodontic bonding and force application
On the basis of simulated model surgery setup, surgical guidance splint is prepared. Before
the surgery, orthodontic bracket bonding/banding is placed but no arch wire is used. Bonding
orthodontic bracket was reported as immediately before surgery [26, 47, 48], 1 week before
surgery [16, 26, 38], and 1–2 months before surgery [50]. Some studies reported the usage
of passive archwire before the surgery [49, 50, 52, 53, 55]. Passive arch can be used 1–3 days
before the surgery [17, 35]. In some cases, the orthodontist can prefer minimal orthodontic
preparation during 6 months [49] before the surgery, and then, they are continuing the orth-
odontic treatment after the surgery. Intermaxillary fixation of jaws during the surgery can
be done by bony screws following the surgical guidance splints placements in cases without
arch wires [47, 50, 51]. Kim et al. maintained intermaxillary fixation without surgical splint
for 2 weeks but used intermaxillary elastic [50]. The osteotomized bones are fixed by rigid
fixation.
Postoperatively, surgical splint is left for 2–4 weeks [34, 50, 53], and intermaxillary elastics
usage may begin after orthodontic wire was placed.
There is no definitive consensus about postsurgical orthodontic force application time. But
generally, the orthodontic treatment in SFA begins in 1 or 2 weeks after surgery. The surgical
splint and inter-maxillary fixation were removed for the tooth movement. Liao et al. reported
that postsurgical orthodontics begun immediately after surgery [17]. This is beneficial to
shorten the orthodontic treatment time due to the regional accelerated phenomena. The stud-
ies showed that the orthognathic surgery triggers a 3- to 4-month period of higher osteoclastic
activity, serum findings, and metabolic changes and that in the dentoalveolar bone postop-
eratively [15, 56]. Archwire changes took place every 2–3 weeks. Arch coordination may be
managed with transpalatal elastics or active transpalatal arch. In segmental surgery patients,
passive continuous arches which were placed before surgery are changed with sectional
arches at first orthodontic appointment after surgery.
5. Relapse in SFA
The short- and long-term relapse rates in SFA have been investigated, and the results are
good by comparison with the conventional surgical approach with a maximum follow-up of
3 years [19, 57–59]. Without presurgical orthodontics, the patients may have likely to develop
unstable occlusion after surgery leading to relapse. However, some of the comparative studies
between conventional and surgery first approach showed no statistical differences in relapse
and almost equal for those achieved using the more traditional orthodontics-first approach
[17, 19, 51, 53, 59–63]. Advancement of fixation system enabled more stabilized results due to
more stable fixation of bony segments. On the other side, based on one research and on the
meta-analysis, SFA showed more relapses than in the conventional approach [57, 64]. Larger
overbite, a deeper curve of Spee, a greater negative overjet, and a greater mandibular setback
were reported to affect stability in SFA cases [59].
Surgery First Approach 151
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Although there are benefits of the SFA, there are some difficulties like the prediction of final
occlusion, instability of postsurgical transient occlusion [10, 65], the requirement of presurgical
orthodontic setup before surgery in some complex cases, and requirement of frequent orthodon-
tic appointment due to RAP. The treatment plan requires detailed and meticulous planning.
6. Conclusion
The surgery first approach is an alternative method that may be more satisfying for ortho-
dontists and patients by minimizing the treatment time required for orthodontic treatment
compared to conventional approach.
Author details
Ayşe Gülşen
Department of Plastic Reconstructive and Esthetic Surgery, University of Gazi, Ankara,
Turkey
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