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This article explains the rationale and indications for the surgery-first approach (SFA).
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This article illustrates step-by-step the sequence to implement SFA with virtual surgical planning.
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This article describes 2 case reports of patients treated with SFA.
Oral and Maxillofacial Surgery Clinics of North America
Surgery-First Approach in the Orthognathic Patient
Section snippets
Key points
Significant advances have occurred in the treatment of dentofacial deformities with orthognathic surgery since the start of this new millennium. One of the main advances has been with 3-dimensional (3D) virtual surgical planning, which has
Indications for surgery-first
Although most patients with dentofacial deformity could be treated with the surgery-first approach, there are clear indications for the technique. Typically, a nonextraction orthodontic treatment is performed in surgery-first. Therefore, a patient with mild to moderate crowding in the maxilla and in the mandible is a good candidate for this approach. In addition, the maxillary incisor inclination has to be near normal. Together, the minimal to moderate amount of crowding and the close to normal
Treatment planning the surgery-first patient
There are 2 major aspects that need to be considered in the patient undergoing orthognathic surgery with surgery-first. These 2 elements are esthetics and occlusion. These 2 aspects are not different from those to be considered in the patient having the conventional 3-stage surgical approach. Most often, resolving the skeletal dysmorphology will resolve the malocclusion. For example, a patient with a significant mandibular deficiency will likely have a Class II malocclusion with a large
Executing the surgery-first approach
Once the patient has been planned 2-dimensionally through a digital software planner, a cone-beam computed tomography (CBCT) scan of the patient is acquired. Typically, this visit is 2 weeks before the surgical procedure to ensure that enough time is available for the manufacturing of the surgical splints. In this appointment, a preliminary plan is already in place that will be refined after obtaining a CBCT. When this scan is acquired, the patient has all the bands and brackets cemented and
Patient 1
The following case report illustrates the typical treatment planning process in a patient in whom all of the ideal parameters for a surgery-first approach were observed. Specifically, this 17-year-old female patient had a minor facial concavity with slight mandibular prognathism and slight maxillary deficiency (Fig. 1A–C). A slight mandibular asymmetry was noted with the chin point deviated approximately 3 mm to the left. The incisor display at rest and smile was very close to normal. The
Summary
Surgery-first is a paradigm shift in orthognathic surgery. Its approach is justified from a patient-centered treatment strategy. Treatment duration may be reduced in certain patients in whom no significant orthodontic movements are required. Skeletal anchorage with this approach offers a mechanical advantage that allows implementation of this technique to most dentofacial deformities. Future directions are the implementation of this approach with clear aligner therapy for an adult population
Acknowledgments
The authors acknowledge Drs Greg Ross and Jonathan Dzingle who contributed to the orthodontic treatment of the patients reported in this article. Also, we acknowledge Drs David Shafer and Derek Steinbacher for performing the orthognathic surgeries on these patients.
References (15)
- et al.
Surgery-first orthognathic approach vs traditional orthognathic approach: oral health-related quality of life assessed with 2 questionnaires
Am J Orthod Dentofacial Orthop
(2017) - et al.
Surgery-first approach in orthognathic surgery: Psychological and biological aspects—a prospective cohort study
J Craniomaxillofac Surg
(2017) - et al.
Oral surgeons' considerations in surgical orthodontic treatment
Dent Clin North Am
(1988) - et al.
Surgery first in orthognathic surgery: what have we learned? A comprehensive workflow based on 45 consecutive cases
J Oral Maxillofac Surg
(2014) - et al.
Can a surgery-first orthognathic approach reduce the total treatment time?
Int J Oral Maxillofac Surg
(2017) - et al.
Surgery first in orthognathic surgery: a systematic review of the literature
Am J Orthod Dentofacial Orthop
(2016) - et al.
Prospective, multi-center study of the effectiveness of orthodontic/orthognathic surgery care in the United Kingdom
Am J Orthod Dentofacial Orthop
(2009)
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Surgery first with clear aligners for a Class II patient: Case report and literature review
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2023, Oral and Maxillofacial Surgery Clinics of North AmericaSurgery first in cosmetically driven orthognathic surgery
2022, Seminars in OrthodonticsCitation Excerpt :This article will highlight the surgery first approach with ancillary cosmetic procedures and the combination with clear aligners in patients driven primarily by a facial esthetics makeover. The specific aspects of planning and executing surgery first has been described elsewhere.3 Incorporation of fat grafting to the surgical procedure is geared to normalize or enhance some of the soft tissue volumes such as the lips.
Insights into concepts, protocols, and evidence of surgery-first orthognathic approach-The journey so far
2022, Seminars in OrthodonticsCitation Excerpt :The protocols for presurgical preparation for the SFOA vary depending on the surgeon and the orthodontist's preferences. Although the SFOA does not technically involve any presurgical orthodontics, fixed orthodontic appliances are frequently placed preoperatively to facilitate post-operative orthodontic treatment.4,14,19 Several options for presurgical preparation for the SFOA include but are not limited to: (1) preoperative placement of a surgical arch bar without archwire, (2) preoperative placement of anchor screws without archwire, (3) preoperative placement of light round or light rectangular wires (with or without screws or anchor plates), (4) preoperative placement of conventional passive, rectangular wires attached with surgical hooks (with or without anchor screws).14
Disclosure: The authors have nothing to disclose.