Int. J. Oral Maxillofac. Surg.

2016; 45: 472475

http://dx.doi.org/10.1016/j.ijom.2015.10.008, available online at http://www.sciencedirect.com

Systematic Review
Orthognathic Surgery

Mandible-first sequence in A. M. Borba1,2,3, A. H. Borges1,

P. S. Ce1, B. A. Venturi4,
M. G. Naclerio-Homem2, M. Miloro3

bimaxillary orthognathic
1
Master of Science Program on Integrated
Dental Sciences, Faculty of Dentistry of the
University of Cuiaba UNIC, Cuiaba, Brazil;
2
Department of Oral and Maxillofacial

surgery: a systematic review Surgery, Traumatology and Prosthesis,

Faculty of Dentistry of the University of Sao
Paulo USP, Sao Paulo, Brazil; 3Department
of Oral and Maxillofacial Surgery, University of
Illinois at Chicago, Chicago, IL, USA; 4Master
A. M. Borba, A. H. Borges, P. S. Ce, B. A. Venturi, M. G. Naclerio-Homem, M. of Science Program on Orthodontics, Sao
Miloro: Mandible-first sequence in bimaxillary orthognathic surgery: a systematic Leopoldo Mandic Research Center,
Campinas, Brazil
review. Int. J. Oral Maxillofac. Surg. 2016; 45: 472475. # 2015 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.

Abstract. The sequencing of bimaxillary orthognathic surgery remains controversial,

although the traditional maxilla-first approach is performed routinely. The goal of
this study was to present a systematic review of the mandible-first sequence in
bimaxillary orthognathic surgery, to provide data that may assist in the decision as
to which jaw should undergo osteotomy first in bimaxillary orthognathic surgery
cases. A literature search was conducted for articles published in the English
language, reporting the use of the altered sequence for bimaxillary orthognathic
surgery (mandible-first), using the following descriptors: orthognathic and
double-jaw, orthognathic and two-jaw, orthognathic and mandible-first,
orthognathic and bimaxillary. Eight hundred eighty-seven abstracts were
initially identified and were evaluated for inclusion according to the proposed
inclusion criteria. After evaluation of these abstracts and relevant references, six
publications met the criteria for consideration. Performing mandible-first surgery in
bimaxillary orthognathic cases dates back to the 1970s; however the decision
regarding the jaw to be operated on first seems to rely on accurate preoperative
Key words: orthognathic surgery; bimaxillary;
planning based upon the surgeons experience and preference. While there appear to double-jaw; two-jaw; altered sequence.
be significant theoretical advantages to support the use of the altered orthognathic
sequence (mandible-first), future prospective studies on its reliability, accuracy, and Accepted for publication 9 October 2015
short- and long-term outcomes are required. Available online 18 November 2015

Dentofacial deformities are defined as
skeletal abnormalities affecting the max-
illa, mandible, or both jaws. The teeth
located in the alveolar process of the
affected bone(s) will frequently present
with malocclusion, crowding, dental com-
pensations, rotations, and misalignments.
Orthodontic treatment may be sufficient to
manage mild dentoskeletal discrepancies,
but as the magnitude and severity of the
discrepancy increases, treatment with
combined orthodontics and orthognathic
surgery will be required.
Orthognathic surgery may be performed
as a single-jaw procedure in which only
the maxilla or the mandible is operated on,
but when the diagnostic records and pre-
surgical planning indicate that both jaws
need to be osteotomized, bimaxillary (or
double-jaw) orthognathic surgery must be
planned. The sequencing of bimaxillary
orthognathic surgery has been the subject
of debate for decades.14 Recently, several
articles have addressed aspects related to

0901-5027/040472 + 04 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

the sequence in bimaxillary surgery, com-
paring the traditional maxilla-first to the
altered mandible-first sequence, and
have highlighted the debate regarding
whether the sequencing choice in bimax-
illary surgery might influence post-surgi-
cal outcomes.2,3,5
The aim of the present systematic re-
view was to examine the existing literature
regarding the development of and scien-
tific evidence related to the mandible-first
sequence in bimaxillary orthognathic sur-
gery, in order to provide data that may
assist surgeons in determining the jaw that
should be operated on first in bimaxillary
orthognathic cases.
Materials and methods
A systematic review was conducted, based
on the PRISMA guidelines (http://www.
prisma-statement.org). The PubMed,
Cochrane Library, and Scopus databases
were searched for publications in the En-
glish language, without any restriction on
the type of study (all searched up to 3 June
2015). The search strategy was defined by
the following terms: orthognathic and
double-jaw, orthognathic and two- quence.
jaw, orthognathic and mandible-first,
orthognathic and bimaxillary.
Inclusion criteria encompassed any men-
tion of the mandible-first sequence within
the abstract of any article generated by the
search, without any restriction on the type
of study. The exclusion criterion was the
absence of any reference to the mandible-
first sequence within the abstract.
The systematic search was conducted
by one author (A.M.B.), and two authors
(A.M.B., P.S.C.) independently per-
formed the screening of titles and
abstracts. Once an article abstract was
selected according to the eligibility crite-
ria (inclusion and exclusion), the full-text
article was read, including the references.
Any reference that could contribute to the
purpose of the systematic review was
retrieved. The two authors then presented
their list of eligible studies and any differ-
ence was discussed until consensus was
reached.
Results
With the application of the search criteria,
the initial search identified a total of 887
abstracts from the different databases
(Fig. 1). After reading the full-text ver-
sions of the corresponding articles and
relevant references, six articles were se-
lected (Table 1). The contents of these six
articles addressed the topic of mandible-
first bimaxillary orthognathic surgery.
Fig. 1. Flow diagram (PRISMA format) of the screening and selection process.
The 884 articles excluded following the
review of abstracts were either duplicates
or did not mention the mandible-first se-
The first mention of the altered se-
quence for bimaxillary orthognathic sur-
gery was provided by Lindorf and
Steinhauser in 1978.6 They stated that
bimaxillary orthognathic surgery should
start with the mandible, since a stable
reference (the maxilla) is needed to accu-
rately reproduce the surgical movements
predicted during model surgery to corre-
spond to the actual surgery. The authors
performed model surgery starting with the
maxilla, then assembling the mandible in
the desired final position for the construc-
tion of the final inter-occlusal splint; later,
the maxilla was returned to its original
position, and an intermediate splint fabri-
cated.
In the 1980s, Buckley et al. highlighted
the disadvantages of starting bimaxillary
orthognathic surgery with the maxilla, due
to the instability of an already operated
maxilla that could be displaced during
mandibular manipulation and fixation.7
With two maxillary cast models and one
mandibular cast model mounted on a
Table 1. Selected publications on the mandible-first orthognathic sequence.
Year Authors, Ref.
6
1978 Lindorf and Steinhauser
1987 Buckley et al.7
1994 Cottrell and Wolford1
2006 Posnick et al.4
2011 Perez and Ellis2
2014 Ritto et al.5
Mandible-first orthognathic surgery 473
semi-adjustable articulator, the authors
also proposed model surgery to begin with
the maxilla, since surgery itself would
start with the mandible having the uncut
maxilla as a stable reference for the oper-
ated mandible. The need for rigid fixation
instead of wire osteosynthesis for this
technique was emphasized.
In the following decade, Cottrell and
Wolford published their experience of
commencing bimaxillary orthognathic
surgery with the mandible first.1 The
authors proposed model surgery to start
with the mandible based upon the predic-
tion of its position on the final occlusion,
thus eliminating errors related to achiev-
ing centric relation for model surgery.
Moreover, they suggested that even in
segmental maxillary surgery, the use of
a final splint would be an option; however,
their preference was for direct dental inter-
digitation to achieve the final planned
occlusion, in order to eliminate interfer-
ences from the splint. It was suggested that
these modifications would reduce the time
and materials required for this planning
step and also result in improved accuracy.
Surgery was started with the mandible
as long as rigid fixation was used, and
Source Type of study
Manual search Case report
Manual search Case report
Manual search Case report
PubMed, Scopus Case report
PubMed, Scopus Case report
PubMed, Scopus Research article
474 Borba et al.
attention was given to properly seating the
condyles in their fossa during the stabiliza-
tion of the proximal mandibular segments.
The lack of reliability of the mandible
as a stable reference was the subject of
another publication related to orthognathic
surgery. In 2006, Posnick et al. reported
that some patients would present difficul-
ties in registration of centric relation, such
as those with congenital incomplete for-
mation or absence of a mandibular con-
dyle (as in hemifacial microsomia) and
those with total or partial loss after tumour
resection or condylar fracture.4 They stat-
ed that in cases without a reliable centric
relation, the model surgery sequence
should start with the maxilla, and the
traditional bimaxillary orthognathic sur-
gery (maxilla-first) should be modified
to the mandible-first sequence.
The controversy over the choice of the
initial jaw osteotomy for bimaxillary
orthognathic surgery was recently debat-
ed. Turvey stated that it should be a sur-
geons decision whether the maxilla or the
mandible will be the first jaw cut in bimax-
illary surgery.3 In addition, Perez and Ellis
detailed specific instances in which it
would be preferable to start the surgery
with the mandible, exemplified by modi-
fication of the mandibular position used
for model surgery after general anesthe-
sia.2 These specific examples warranting
consideration of the mandible-first se-
quence include the following: cases of
bimaxillary orthognathic surgery in which
down-grafting of the posterior maxilla is
planned; when centric relation registration
for model surgery is uncertain; when inter-
maxillary fixation is impaired by a thick
intermediate splint if surgery starts with
the maxilla; when fixation of the maxilla is
not rigid; when concomitant temporoman-
dibular joint surgery is planned with the
orthognathic procedure. Model surgery
could start with the mandible when only
one set of dental models is available, or
start with the maxilla when two sets of
models are mounted on an articulator.
The most recent article selected was the
first study to compare whether the choice
of jaw operated on first would interfere
with the outcomes of orthognathic sur-
gery. In 2014, Ritto et al., using a retro-
spective sample, demonstrated that the
maxilla could be accurately placed in
the predicted position, regardless of the
choice of the initial jaw operated on for
bimaxillary surgery.5
Discussion
During the early years following the in-
troduction of bimaxillary orthognathic
surgery (in the 1960s), Obwegeser con-
fronted the dilemma of which jaw to op-
erate on first in bimaxillary orthognathic
surgery. At that time, he performed the
osteotomy of both jaws first, having both
of them mobilized from the facial skele-
ton, and used intermaxillary fixation; he
then fixated the maxilla and the mandible
into their planned positions.8
Since then, orthognathic surgery has
evolved, with modifications made to the
surgical technique, changes made to the
materials used for internal fixation of the
osteotomized bony segments, and the use
of virtual surgical planning. The advent of
rigid internal fixation was essential to
allow the mandible to be the first segment
operated on in bimaxillary orthognathic
surgery, but there are other reasons to
consider this altered sequence.1,2,57
Model surgery techniques have also
been modified over the years. Lindorf
and Steinhauser used only one maxillary
cast for model surgery planning, which
would vary back and forth from the op-
erated to the original position for splint
fabrication. In contrast, Buckley advocat-
ed the need for two maxillary casts
mounted on a semi-adjustable articulator,
thus maintaining one of the maxillary
models in the original position, while
the other maxillary cast was maintained
in the operated position.6,7 The advan-
tage of having two maxillary models
mounted on the articulator is the ability
to modify the model surgery protocol at
any time, changing the sequence (tradi-
tional to altered, and vice versa) or even
the surgical movements for each segment,
since an original pair of casts (maxilla and
mandible) would always be available.2
The difficulty in reproducing centric
relation for model surgery as the reason
for starting bimaxillary orthognathic sur-
gery with the mandible, was first described
by Cottrell and Wolford in 1994, but has
more recently been supported by
others.1,2,4 The ability to have a stable
reference (i.e. the maxilla) to position
the unstable freely-movable mandible
seems logical in several instances, which
could occur due to technical errors when
reproducing centric relation on the articu-
lator for model surgery, secondary to func-
tional or morphological alterations at the
temporomandibular joint level, or due to
the effects of a supine patient position
and general anaesthesia on condylar
positioning.1,2,4,5,911 While the maxilla-
first sequence is generally preferred, the
modified surgical sequence (mandible-
first) would be favoured in situations such
as counterclockwise rotation of the occlusal
plane thus avoiding an intraoperative
anterior open bite, inaccuracy of inter-oc-
clusal records and uncertainty in precise
condylar positioning, concomitant TMJ
surgery, or an expected difficulty in maxil-
lary fixation as seen in segmental maxillary
osteotomies.1,2
The altered bimaxillary orthognathic
surgery sequence (mandible-first) might
not be preferred with other surgical move-
ments. Clockwise rotations of the occlusal
plane and maxillomandibular rotations
using posterior maxillary intrusion or an-
terior maxillary extrusion would require
the mandible to be fixed in an open-bite
intermediate position with a thick inter-
mediate splint in the incisor region, mak-
ing the application of intermaxillary
fixation difficult.2 Also, in cases undergo-
ing the mandible-first sequence in which
an unfavourable split of the mandible
occurs that is not correctable during sur-
gery, maxillary surgery will have to be
postponed until a later date.1
In terms of accuracy of orthognathic
surgery, the traditional sequence of
bimaxillary orthognathic surgery (maxil-
la-first) offers variable but well-documen-
ted results with acceptable outcomes.1214
On the other hand, the literature on the
altered sequence (mandible-first) provides
little outcomes data, and its use is current-
ly supported only by the opinion of authors
and a single retrospective case series.1,2,4
7
Moreover, the role of orthognathic vir-
tual surgical planning, in which bony
interferences due to premature segment
contacts may be anticipated and the thick-
ness of the intermediate splint can be
assessed for beginning the surgery with
either the maxilla or the mandible, is yet to
be evaluated.
The decision to operate on the mandible
as the first jaw in a bimaxillary orthog-
nathic procedure dates back to the 1970s.
However, up until the present time the
decision regarding which segment should
be operated on first has relied on accurate
preoperative planning based upon individ-
ual surgeon experience and preference.
While there appear to be significant theo-
retical advantages to support the use of the
altered orthognathic sequence (mandible-
first), future prospective studies on its
reliability, accuracy, and short- and
long-term outcomes are required.
Funding
There was no financial support for the
present research.
Competing interests
None declared.

Ethical approval
Not required.
Patient consent
Not required.
References
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Address:
Alexandre Meireles Borba
Hospital Geral Universitario Divisao de
Odontologia
Rua Treze de Junho
2101
Centro
Cuiaba
MT CEP 78025-000
Brazil
Tel: +55 65 3315 7150
E-mail: alex80@terra.com.br