Surgery First in Bi Maxillary Orthognathic Surgery

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J Oral Maxillofac Surg69:e201-e207, 2011

“Surgery First” in BimaxillaryOrthognathic Surgery

Federico Hernández-Alfaro, MD, DDS, PhD, FEBOMS,*

Raquel Guijarro-Martínez, MD,† Ana Molina-Coral, DMD,‡

and Consuelo Badía-Escriche, DMD§

The general formula in traditional orthognathictreatment has consisted of a variable length of pre-operative orthodontic preparation, surgery itself,and a relatively constant period of postoperativeorthodontics.1 Patients have usually expressed highlevels of satisfaction with the esthetic and func-tional outcomes, especially if they were accuratelyinformed about all aspects of their treatment.2

However, an important percentage of patients willrate the orthodontics as the worst part of theirtreatment owing to the appliances’ visibility, thepain caused, and the duration.3 The usual estimatedduration of orthodontic treatment has often tendedto be too optimistic.4

Recently, the performance of surgery without orth-odontic preparation (ie, “surgery first”), followed byregular postoperative dental alignment, was proposedby Nagasaka et al.5 The authors used this approach tocorrect skeletal Class III malocclusion with the aid ofskeletal anchorage system orthodontics. The totaltreatment time was noticeably reduced. In addition,preoperative profile worsening owing to incisor de-compensation was avoided and the immediate profileimprovement after the surgery was greatly appreci-ated by the patient.5

*Oral and Maxillofacial Surgeon, Head, Institute for Maxillofacial

Surgery and Implantology, Teknon Medical Center, Barcelona,

Spain; Clinical Professor in Oral and Maxillofacial Surgery and

Director, Master Program in Implant Dentistry, Universitat Interna-

cional de Catalunya, Barcelona, Spain.

†Resident in Oral and Maxillofacial Surgery, Fellow, Institute for

Maxillofacial Surgery and Implantology, Teknon Medical Center,

Barcelona, Spain.

‡Orthodontist, Associate Professor in Orthodontics, Universitat

Internacional de Catalunya, Barcelona, Spain.

§Orthodontist, Private Practice, Valencia, Spain.

Address correspondence and reprint requests to Dr Guijarro-

Martínez: Institute for Maxillofacial Surgery and Implantology,

Teknon Medical Center Vilana 12D-185, Barcelona 08022, Spain;

e-mail: [email protected]

© 2011 American Association of Oral and Maxillofacial Surgeons

278-2391/11/6906-0075$36.00/0

oi:10.1016/j.joms.2011.01.010

e201

The purpose of the present study was to report ourexperience with the “surgery first” approach in 2cases of bimaxillary surgery.

Patients and Methods

Two patients were treated with bimaxillary surgeryusing the “surgery first” approach at the Institute ofMaxillofacial Surgery and Implantology of the TeknonMedical Center (Barcelona, Spain) during 2010. TheHelsinki Declaration guidelines were followed in alltreatment phases. Under institutional review boardapproval, a prospective evaluation was performed.

The inclusion criteria for the “surgery first” se-quence were skeletal malocclusions requiring com-bined orthodontic-surgical treatment with no needfor extractions. The patients were informed about thetreatment protocol and provided treatment-specificwritten informed consent. In one case, the orthodon-tic appliances were installed after the surgery wasperformed; in the other, the protocol was modified toplace them right before the surgical stage.

Preoperative cone-beam computed tomographywas performed in both cases. The IS i-CAT, version17-19 (Imaging Sciences International, Hatfield, PA),was used. A 7-second scan was taken with the patientsitting upright, with the clinical Frankfort horizontalplane parallel to the floor and the mandible in centricrelation with the help of a wax bite. With the aid ofspecific software (SimPlant OMS, version 13.0; Mate-rialize, Leuven, Belgium), a virtual orthodontic andsurgical setup was done to anticipate the future dentaland skeletal movements. First, an orthodontic setupwas performed to anticipate the final position of theupper and lower incisors. Using the anticipated orth-odontic setup and following the clinical guidelines,6

the surgical planning was completed.Both procedures were performed with the patient

under general anesthesia by the same surgeon. Patientsatisfaction was evaluated using a visual analog scaleranging from 1 (least satisfied possible) to 100 (mostsatisfied possible).

CASE 1

A 23-year-old woman had been referred by her
orthodontist with the complaint of an open bite. She
mailto:[email protected]

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e202 “SURGERY FIRST” IN BIMAXILLARY ORTHOGNATHIC SURGERY

had undergone a 3-year orthodontics-only treatment 6years earlier, and the bite had reopened shortly afterthe removal of the appliances (Fig 1). She had noesthetic concerns; in fact, she requested no facialchanges apart from those strictly related to the cor-rection of her malocclusion. She was extremely con-cerned with having to again undergo a long orthodon-tic treatment.

Frontal inspection revealed long face syndrome be-cause of the skeletal open bite. The radiologic andclinical profile evaluation revealed a biretrusive con-tour with an anterior open bite (Fig 2). Occlusally, sheexhibited an angle Class II malocclusion with trans-verse maxillary deficiency, a pronounced curve ofSpee in the upper jaw, and moderate crowding in thelower. A diagnosis of long face, biretrusive, with ananterior open bite, transverse deficiency of the max-illa, and crowding in the mandible was established.

The virtual orthodontics setup excluded the needfor extractions. The treatment plan included a seg-mented Le Fort I maxillary osteotomy with 5-mmadvancement, 4-mm expansion, and 3-mm posteriorimpaction, plus bilateral sagittal split osteotomies(BSSO) for mandibular advancement of 8 mm andcounterclockwise rotation. Virtual surgical planningallowed for the generation of an intermediate com-puter-assisted design, computer-assisted manufactur-ing (CAD/CAM) splint. The final splint was preparedusing plaster models in a nonadjustable articulator.Because of the lack of splint support owing to theabsence of regular orthodontic appliances, extra re-tention was given to the final splint.

Surgery was performed 3 weeks after the first ap-pointment. The usual maxilla-first approach was fol-lowed (Fig 3). Before starting the osteotomies, 6 an-chorage screws were placed transmucosally to assist

FIGURE 1. Preoperative occlusion of patient 1, who had pre-sented with primary occlusal complaints.

Hernández-Alfaro et al. “Surgery First” in Bimaxillary Orthog-nathic Surgery. J Oral Maxillofac Surg 2011.

in intraoperative stabilization of the segments and n

splints. Microscrews were used to avoid loading ofthe recently bonded brackets. The planned surgicalmovements were executed (Fig 4). Fixation of the4-piece maxilla was achieved with 4 titanium mini-plates and 16 screws. The BSSO for advancement wasstabilized with 2 plates and 8 screws. The final splintwas left in place to aid in transversal contention ofthe expanded maxilla. The operative time was 78minutes.

Her postoperative recovery was uneventful. Shewas discharged from the hospital 24 hours after thesurgery. At 2 weeks postoperatively, the final splintwas removed, and the orthodontic movements werebegun using round wires and intermaxillary elastics.

CASE 2

A 20-year-old woman checked into our institutewith the complaint of facial disharmony (Fig 5). Shereported emotional and social disability because ofher facial deformity. She requested corrective surgeryas soon as possible and hoped it could occur beforeshe started university 2 months later.

The clinical and radiologic examination revealed askeletal Class III malocclusion with maxillary defi-ciency and mandibular asymmetry (Fig 6). Cant of theocclusal plane was also evident on frontal inspection.Compensations in the lower jaw were accompaniedby discrete crowding. No transverse problems werepresent.

FIGURE 2. Preoperative profile of patient 1.

ernández-Alfaro et al. “Surgery First” in Bimaxillary Orthog-
athic Surgery. J Oral Maxillofac Surg 2011.

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HERNÁNDEZ-ALFARO ET AL e203

The virtual orthodontic setup ruled out the needfor extractions and verified an adequate position andaxial inclination of the upper incisors. The virtualsurgical treatment plan included Le Fort I maxillaryosteotomy for 7-mm advancement and 4-mm descentand a BSSO for 3-mm retrusion and centering. Just asin the previous case, an intermediate CAD/CAM splintwas generated, and a final splint was crafted from theplaster models placed in a nonadjustable articulator.

Likewise, temporary screws were placed, and amaxilla-first protocol was followed (Figs 7-9). Two

FIGURE 3. Patient 1. Intraoperative view of segmented Le Fort Iosteotomy, with intermediate CAD/CAM splint in place.


FIGURE 4. Immediate postoperative occlusion of patient 1 withtemporary screws in place.

Hernández-Alfaro et al. “Surgery First” in Bimaxillary Orthog-
nathic Surgery. J Oral Maxillofac Surg 2011. n
preformed plates with 7 screws on each were used tostabilize the maxilla, and 2 more with 4 screws eachwere used for the mandible. Autologous fat transferfor cheek recontouring was performed using the tro-chanteric areas as donor sites. The final splint wasremoved at the end of surgery. The orthognathicprocedure lasted 65 minutes, with another 25 min-utes needed for the liposculpturing.

Her postoperative recovery was uneventful, andthe patient was discharged from the hospital the next

FIGURE 5. Preoperative profile of patient 2, who had presentedwith primary esthetic complaints.


FIGURE 6. Preoperative occlusion of patient 2.


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day. Her orthodontics began 10 days after surgery andinvolved arch alignment and leveling, with decom-pensation of the lower arch.

Results

In patient 1, the total orthodontic treatment re-quired 250 days. Arch settlement and levelingachieved a Class I relationship, with adequate rootparallelism that was stable at 1 year of follow-up (Fig10). The patient was satisfied with the esthetic result(Fig 11).

For patient 2, the total orthodontic treatment lasted185 days, after which an adequate Class I occlusionand an esthetically balanced profile was achieved(Figs 12,13).

FIGURE 7. Intraoperative view of Le Fort I osteotomy of patient2.


FIGURE 8. Intraoperative view of BSSO of patient 2.

athic Surgery. J Oral Maxillofac Surg 2011. n
Patient 1 rated the treatment outcome and durationat a score of 95. The orthodontist considered the casechallenging but extremely satisfactory from a time–results perspective. Patient 2 rated satisfaction withthe duration and results of treatment as 100 on thevisual analog scale. The orthodontist considered thecase easy and extremely satisfactory from a time–results and patient-perception perspective.

Discussion

The “surgery first” concept in orthognathic surgerywas introduced by Nagasaka et al5 in 2009. Theyreported the correction of a Class III skeletal maloc-clusion with mandibular setback surgery and subse-quent orthodontic alignment with the aid of tempo-rary anchorage devices. The patient did not undergoany previous orthodontic preparation. Because of

FIGURE 9. Immediate postoperative occlusion of patient 2, withtemporary screws in place.


FIGURE 10. Final occlusion at 1 year of follow-up for patient 1.


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their excellent clinical results and substantial reduc-tion in total treatment time, the investigators postu-lated that this new treatment approach could becomea standard procedure in the future.5 Taking into con-ideration the number of patients requesting orthog-athic surgery with primarily esthetic concerns andime limitations for long treatment, the “surgery first”pproach could represent a reasonable, cost-effectiveethod to manage skeletal maloclussion in selected

ases. However, to our knowledge, no references tohe use of the “surgery first” approach in bimaxillaryrthognathic surgery exist in published scientific re-orts.

FIGURE 11. Postoperative profile of patient 1.

ernández-Alfaro et al. “Surgery First” in Bimaxillary Orthog-athic Surgery. J Oral Maxillofac Surg 2011.

FIGURE 12. Postoperative occlusion, 1 month before bracketdebonding, for patient 2.

Hernández-Alfaro et al. “Surgery First” in Bimaxillary Orthog-
nathic Surgery. J Oral Maxillofac Surg 2011.
Traditional surgical-orthodontic treatment has in-luded 2 orthodontic phases: a preoperative prepara-ion in which most of the orthodontic movements areerformed to achieve a precise, stable occlusion andpostoperative phase for minor adjustments. Preop-

rative orthodontic treatment usually lasts 15 to 17onths,4,7 or even up to 24 months.8 However, the

total preoperative treatment is frequently longer thanthat initially indicated to the patient.4 The averageduration of the postoperative orthodontic phase hasvaried from 7 months9 to 12 months.8 No statisticallyignificant differences regarding patient age, gender,r type of malocclusion have been detected.4,8-10

These orthodontic phases often cause significant dis-comfort to the patient.4,11 One study found that onehird of patients rated the orthodontics as the worstart of their orthognathic treatment owing to theppliances’ visibility and discomfort and the length ofreatment.3

In contrast, if the surgery is performed before theorthodontic treatment, the total treatment time willbe noticeably reduced. Nagasaka et al5 reported thathe treatment could be shortened to about 12onths, less than the average time needed for tradi-

ional preoperative orthodontics alone.4,7,9 In our pa-tients, the total treatment time was 264 days (8.8months) for patient 1 and 195 days (6.5 months) forpatient 2. These data, although lacking statistical sig-nificance, have illustrated that a “surgery first” ap-

FIGURE 13. Postoperative profile of patient 2.

ernández-Alfaro et al. “Surgery First” in Bimaxillary Orthog-athic Surgery. J Oral Maxillofac Surg 2011.

proach tends to condense the treatment time consid-

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erably, mainly by shortening the total orthodonticperiod.

In 2001, Wilcko et al12 suggested that rapid toothovement in the context of corticotomy-facilitated

rthodontics was the result of a demineralization–emineralization process consistent with the woundealing pattern of the regional acceleratory phenome-on. It seems that selective bone injury results in anverwhelming activating stimulus for both cata-olic and anabolic responses in the periodon-ium.13 It is possible that the alveolar bone adjacent

to the osteotomies performed during orthognathicsurgery also undergoes increased bone turnover.14

This could account for the more efficient postop-erative orthodontic movements and hence contrib-ute to the total treatment time reduction in a “sur-gery first” sequence.

Moreover, routine preoperative orthodontics in-volve dental alignment, arch coordination, and incisordecompensation; very often, the latter tends to pro-long the treatment time with little or no significantbenefit to the patient.5 In addition, axial correction ofthe incisors exacerbates an anterior crossbite andtends to unmask the patient’s underlying skeletal de-formity. Especially in the case of Class III patients, theprognathic profile will be greatly accentuated as thepreoperative orthodontics progress. This intensifiesthe patient’s perception of facial disharmony. The“surgery first” approach, in contrast, corrects the skel-etal problem (and hence the esthetic concern) fromthe beginning. This clearly accounted for the favor-able evaluation of the treatment by our secondpatient.

Another advantage of the “surgery first” approachcompared with traditional surgical-orthodontic treat-ment includes the rapid profile improvement withsubsequent immediate patient satisfaction. This wasevident in patient 1, in whom the open bite wasalready closed at the end of surgery. In addition, inthe case of skeletal Class III patients, such as patient 2,the upper lip and tongue tone improvement thatoccurs after mandibular setback increases the forceon the incisors and improves the efficiency of incisordecompensation, adding to the total treatment timereduction.

In contrast, several difficulties and disadvantagesmust be considered. First, the occlusion cannotserve as a guide for the designation of treatmentgoals. Second, the immediate postoperative occlu-sion is often unstable; thus, an occlusal splint whileeating has been recommended.5 Temporary anchor-ge devices can be considered to help stabilize thesteotomies when no solid orthodontic appliancesre present during surgery.5,14 These temporarynchorage devices might later aid in anchoring
rthodontic forces firmly in a specific fashion to
pply all required vectors. In addition, they couldlay a role in compensation of a surgical error orkeletal relapse.5

It is unquestionable that this treatment conceptrequires a precise diagnosis and detailed treatmentplanning. The postoperative orthodontic movementsmust be accurately planned with the surgical plan,implying constant communication between the sur-geon and orthodontist. It is absolutely indispensablethat the orthodontist be skilled in orthognathic sur-gery cases, because the orthodontist is often con-fronted with a rather complex scenario. We have thusrecommended that only experienced teams be in-volved with this approach.

To our knowledge, this is the first report of orthog-nathic bimaxillary cases performed with the “surgeryfirst” sequence. In addition to other advantages, thismethod reduced the total treatment time significantlyand was very well accepted by patients. High orth-odontic efficiency responds to the correction of theskeletal bases as a starting point and accelerated toothmovement owing to the increased postoperative met-abolic turnover. Our first case (anterior open bite,with transverse maxillary deficiency and vertical ex-cess) represented one of the most complex situationsin orthognathic surgery and yet was successfully man-aged with this approach. Our second patient re-quested rapid correction of her esthetically compro-mising profile, and the treatment was completedwithin 6 months. Both patients manifested high satis-faction with the treatment protocol and duration. Athorough diagnosis, planning, and execution couldrender the “surgery first” approach appropriate for agood proportion of our routine cases.

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3. Nurminen L, Pietilä T, Vinkka-Puhakka H: Motivation for andsatisfaction with orthodontic-surgical treatment: A retrospec-tive study of 28 patients. Eur J Orthod 21:79, 1999

4. Luther F, Morris DO, Hart C: Orthodontic preparation fororthognathic surgery: How long does it take and why? A ret-rospective study. Br J Oral Maxillofac Surg 41:401, 2003

5. Nagasaka H, Sugawara J, Kawamura H, et al: “Surgery first”skeletal class III correction using the skeletal anchorage sys-tem. J Clin Orthod 43:97, 2009

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9. Luther F, Morris DO, Karnezi K: Orthodontic treatment follow-ing orthognathic surgery: How long does it take and why? Aretrospective study. J Oral Maxillofac Surg 65:1969, 2007

10. Robb SI, Sadowsky C, Schneider BJ, et al: Effectiveness andduration of orthodontic treatment in adults and adolescents.Am J Orthod Dentofac Orthop 114:383, 1998

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Surgery First in Bi Maxillary Orthognathic Surgery