Professional Documents
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Surgery-First Orthodontic Management
Surgery-First Orthodontic Management
Surgery-First Orthodontic Management
Orthodontic
Management
123
Surgery-First Orthodontic Management
Chai Kiat Chng • Narayan H. Gandedkar
Eric J. W. Liou
Surgery-First Orthodontic
Management
A Clinical Guide to a New Treatment
Approach
Chai Kiat Chng Narayan H. Gandedkar
KK Women’s and Children’s Hospital KK Women’s and Children’s Hospital
Singapore Singapore
Eric J. W. Liou
Chang Gung Memorial Hospital
Taipei, Taiwan
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Dedication from Dr. Gandedkar:
To my parents, Aayi and Appa, ‘I never knew
of the love and sacrifices you made as
parents, until I became one myself’.
To my wife, Krizanne, a gorgeous person
inside-and-out and a true soulmate, and our
two lovely sons, Aryan and Ayush, who make
every day of my life ‘une vie amusante’.
vii
viii Contents
1.1 Introduction
Conventional jaw surgery did originate sometime in the eighteenth century (1849)
[1–3] when an American oral surgeon, Simon Hullihen (considered as the father of
oral surgery), first performed jaw surgery to correct a prognathic mandible. It took
another century (1957) for conventional jaw surgery to become a mainstay treat-
ment for the correction of dentofacial deformity when two Austrian oral surgeons,
Richard Trauner and Hugo Obwegeser, introduced sagittal split osteotomy, which
then marked the foundation of the modern era of jaw surgery [4].
1. Cemented (cast gold) splints impeded the possibility of tooth movement post-
surgery; hence, less emphasis was placed on the correction of malocclusion, and
orthodontists role in jaw surgery was primarily (and restricted) in providing a
surgical splint that represented predetermined post-surgery occlusion [6].
2. Intermaxillary fixation was kept in place for a prolonged period of time [7].
3. Acid-etching technique and bonding agents were in the inception stages [8, 9].
4. Relying on handmade bands and metallic straps for brackets that involved
lengthy appointment time, the mutual belief that orthodontic appliances were too
fragile to stabilize jaw fragments leads to the removal of pre-surgery appliances
(if any) and placement of the arch bars for surgery. Also, placing a new set of
orthodontic appliances after surgery was not only an expensive undertaking but
was impractical too [10].
5. There was a lot of time spent customizing and bending arch wires as superelastic
wires were still in the experimental stage, and were not widely available [11].
6. There was a lack of communication between oral surgeon and orthodontist, as
each fraternity believed working independently of each other. This culture of
working in silos led the orthodontist and oral surgeon to remain unaware of each
other’s field advancements [10, 12, 13].
Our pioneers have done a remarkable job and have achieved a commendable
feat in the field of ‘surgical orthodontics’ despite the scarcity of resources at the
time (antibiotics, local or general anaesthetics, superelastic wires, and bonding
agents were either lacking or not available). In order to overcome the failure rates
of those jaw surgeries that did not accompany pre-surgical orthodontics, there was
more attention paid to the orthodontics part of the surgical case. Also, with the
advent of considerable surge in orthodontic materials, thanks to the ‘technology
boom’ of the 1970s [11], orthodontics saw a new lease of life with emphasis on
technology-driven treatment approach; this change favoured orthognathic-ortho-
dontics management. Worms et al. stated that orthodontics-first concept must be
rigorously employed to all jaw surgery cases where sagittal, vertical, and trans-
verse discrepancies were not possible to be managed by orthodontics alone and
emphasized that optimal surgical repositioning of the maxillo-mandibular com-
plex is only possible following the elimination of all impeding dental compensa-
tion prior to surgery [13, 14].
Subsequently, post-1970, comprehensive orthodontic treatment or commonly
addressed as ‘orthodontic decompensation’ became an integral component of the
jaw surgery management. Many scientific papers have been written since where an
2011 Liou et al ‘Transitional occlusion ‘is established
post-surgery
2011 Hernandez et al Emphasise is laid on diagnosis and
case selection
1973 Bell et al Minimal orthodontic 2010 Villegas et al Facial asymmetry cases were treated
treatment before the with SFOA
1963 Poulton Mandibular surgery proposed
et al set-back 2015 Yu et al SFOA is regarded as an ideal and
1977 Epker and Fish Anterior open bite managed valuable
with SFOA Long term outcome of SFOA and
2015 Choi JW
conventional surgery compared
1988 Behrman et al SFOA could be done Quality of life significantly improved in
2016 Huang et al
SFOA cases compared to conventional
1994 Lee Orthodontic treament easier surgery
to perform post-surgery 2017 Yang et al A Systematic Review and Meta-Analysis
on SFOA
oral surgeon or plastic surgeon teamed with orthodontists managed jaw surgery
patients. Subsequently, the term ‘surgical orthodontics’ was coined. ‘Surgical ortho-
dontics’ saw advancements in three distinct areas:
Conventional jaw surgery has many restrictions and limitations which have led
practitioners to seek a newer paradigm that will essentially address the caveats of
conventional jaw surgery, as enumerated below, and in Table 1.1.
Table 1.1 Table comparing salient features of ‘SFOA’ and ‘conventional jaw surgery’
Salient features SFOA Conventional jaw surgery
Pre-surgery orthodontic 1–4 weeks 12–18 months
treatment
Stages involved Three stages Two stages
• Pre-surgery orthodontics • Jaw surgery
• Jaw surgery • Post-surgery orthodontics
• Post-surgery orthodontics
Post-surgery 12–18 months 6–12 months
orthodontic treatment
time
Impact on facial profile Immediate improvement Potential aggravation led by
worsening of profile before
surgery
Post-surgical stability Yet to be evaluated in detail No immediate post-surgical
instability
Quality of life: Significant benefits with the Negative impact on the
self-esteem, body surgery-first approach perception of patients’ quality
image, level of of life
satisfaction
Early elimination of Possible to eliminate imbalances in Not possible; in fact, worsens
soft and hard tissue the beginning of treatment due to due to ensued decompensation
hindrances establishment of proper maxillo- mechanism
mandibular relationship, thereby
allowing efficient dental correction
Patient satisfaction rate High patient satisfaction rate is Patients cannot appreciate the
associated with improved immediate corrections due to
cooperation during postoperative pre-surgical orthodontics
orthodontics phase
Surgery option Surgery can be opted based Surgery timing can’t be
according to patients’ will chosen as the patient has to
wait until pre-surgical
decompensation is completed
Overall treatment time 1–1.5 years 3–4 years
Patient selection criteria Critical for the success of treatment Non-critical, complex cases
as the baseline dental relation is can be managed with
unable to guide the post-surgery appropriate pre-surgical
occlusion. The orthodontist decompensation stage
experience in assessing and
predicting accurate post-surgery
tooth movement plays a vital role
6 1 Introduction to Surgery-First Orthognathic Approach (SFOA)
1.5 Conclusion
Jaw surgery is coming into a new era of management where patients and practitio-
ners both benefit. As Thomas S. Kuhn, who coined the term ‘paradigm shift’,
describes ‘paradigm shift’ as an undeniable discovery that is thoroughly undoing
the accepted knowledge and beliefs [16]; and so is SFOA, which has poised itself to
undo the previous conventions with which we have approached jaw surgery man-
agement. Dr William Bell’s statement on paradigm shift in jaw surgery sums up
what is in store.
‘They won’t buy that stuff anymore’. ‘The old ways of doing business are over’. ‘We need
to make new alliances’. ‘Others are waiting to seize our turf’. [17]—Dr. William Bell on
‘Paradigm Shifts in Jaw Surgery’
References
1. Poulton D, Ware W. The American academy of oral roentgenology joins our journal. Oral Surg
Oral Med Oral Pathol. 1959;12:389–90.
2. Aziz SR. Simon P. Hullihen and the origin of orthognathic surgery. J Oral Maxillofac Surg.
2004;62:1303–7.
3. Hayward J. The legacy of Simon P. Hullihen. J Hosp Dent Pract. 1976;10:73–4.
4. Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia
with consideration of genioplasty: part I. Surgical procedures to correct mandibular progna-
thism and reshaping of the chin. Oral Surg Oral Med Oral Pathol. 1957;10:677–89.
5. Huang C, Hsu S, Chen Y-R. Systematic review of the surgery-first approach in orthognathic
surgery. Biom J. 2014;37:184.
6. Ottolengui R. A friendly criticism of Dr. Angle’s proposed technique in surgical correction of
mandibular protrusion. Dental Cosmos. 1903;45:454–7.
7. Juniper R, Awty M. The immobilization period for fractures of the mandibular body. Oral Surg
Oral Med Oral Pathol. 1973;36:157–63.
8. Gwinnett A, Matsui A. A study of enamel adhesives: the physical relationship between enamel
and adhesive. Arch Oral Biol. 1967;12:1615–IN46.
9. Buonocore M, Matsui A, Gwinnett A. Penetration of resin dental materials into enamel sur-
faces with reference to bonding. Arch Oral Biol. 1968;13:61–IN20.
10. Proffit WR, White RP. Development of surgeon-orthodontist interaction in orthognathic sur-
gery. Semin Orthod. 2011;17:183–5.
11. Kusy RP. Orthodontic biomaterials: from the past to the present. Angle Orthod. 2002;72:501–12.
12. Proffit WR, White RP Jr. Combined surgical-orthodontic treatment: how did it evolve and what
are the best practices now? Am J Orthod Dentofacial Orthop. 2015;147:S205–S15.
13. Biederman W. The orthodontist's role in resecting the prognathic mandible. Am J Orthod.
1967;53:356–75.
14. Worms FW, Isaacson RJ, Michael ST. Surgical orthodontic treatment planning: profile analysis
and mandibular surgery. Angle Orthod. 1976;46:1–25.
15. Lee R. The benefits of post-surgical orthodontic treatment. Br J Orthod. 1994;21:265–74.
16. Kuhn TS, Hawkins D. The structure of scientific revolutions. Am J Physiol. 1963;31:554–5.
17. Assael LA. The biggest movement: orthognathic surgery undergoes another paradigm shift.
Philadelphia, PA: WB Saunders; 2008.
Diagnosis and Treatment Planning
of Surgery-First Orthognathic Approach 2
2.1 Introduction
Diagnosis and treatment planning forms the basis of successful treatment planning.
The chapter entails orthodontic and surgical considerations with case selection and
guidelines. Both conventional and 3D surgical planning are discussed. Careful con-
sideration of specific landmarks and planes leads to successful planning and execu-
tion of maxilla-mandibular complex deformity. Emphasis is laid on the understanding
and visualizing of the post-surgery ‘transitional occlusion’. Further, the transitional
occlusion could be transpired into final occlusion in the post-surgery phase of orth-
odontic treatment.
Data Gathering
Envelope of Discrepancy
Transitional
occlusion
Mild or no ortho
Case selection criteria Moderate to severe
treatment
Dental Skeletal
consideration consideration
Treatment plan
For beginners, cases with minimal dental discrepancies, in sagittal, vertical, and
transverse planes, could be ideal cases to start with for SFOA.
Some clinical examples would be:
The flow chart in Fig. 2.2 explains the SFOA treatment guidelines in the form of
sagittal, vertical, and transverse planes, along with the type of skeletal and dental
considerations. The flow chart assists in formulating a transitional occlusion for the
malocclusion to be treated simply with orthodontics post-surgery. The flow chart
also explains which type of surgery is best suited for the resolution of skeletal con-
ditions along with recommendations of extraction or non-extraction approach with
emphasis on post-surgery considerations for the orthodontist.
SFOA can be carried out by two different approaches:
moderate
retroclined lower segmental osteotomy +
+ BSSO set-back
Class III crowded lower incisors Align lower incisors
Set-up occlusion in utilizing the large
Class I relationship overjet
Proclined Le Fort I osteotomy with
maxillary incisors clockwise rotation +
BSSO set-back
To correct crossbite
Skeletal cross bite ≤
postoperatively
molar width
Cross bite
Differential impaction of
Anterior open maxilla with clockwise Set-up occlusion in Intrude posterior
bite rotation + BSSO Class I relationship teeth, consider TAD’s
advancement
Vertical
Differential impaction of
maxilla with clockwise Set-up occlusion in Intrude posterior
Class III Anterior open bite rotation + BSSO Class I relationship teeth, consider TAD’s
setback
Fig. 2.2 Flow chart explains the SFOA treatment guidelines in the form of sagittal, vertical, and
transverse planes
10 2 Diagnosis and Treatment Planning of Surgery-First Orthognathic Approach
2.2.1 Orthodontic-Driven
This encompasses correction of skeletal problems with jaw surgery and dental prob-
lems using skeletal anchorage system. This aforementioned technique was popular-
ized by Sugawara and team of Japan and eventually named it as ‘Sendai surgery
first’ (SSF) [1, 2]. The basic tenets of SSF lie in controlling the post-surgical orth-
odontic biomechanics with the help of skeletal anchorage system. The proponents
of this approach claim that application of SAS post-surgery enables control of the
entire dentition, including the three-dimensional control of bimaxillary molars, and
facilitates correction of a wide range of complexities. However, some of the draw-
backs of this technique are (1) overreliance on SAS, (2) post-surgical complex orth-
odontic tooth movement, (3) added cost of SAS, and (4) additional surgical
intervention for removal of SAS post-treatment.
2.2.2 Surgery-Driven
The proponents of this technique espouse that both skeletal and complex dental
problems are corrected with jaw surgery thus allowing only orthodontically treat-
able malocclusion to persist post-surgery in the form of transitional malocclusion
such that routine orthodontics biomechanics is employed to correct the malocclu-
sion utilizing regional acceleratory phenomenon [3–8].
SFOA is a ‘one patient two problem concept’, wherein the skeletal and dental are
two separate problems which need to be addressed in one patient. The skeletal com-
plexities are corrected via jaw surgery, and a ‘transitional occlusion’ is set up such
that the second problem, i.e. the dental problem, is managed with conventional orth-
odontic treatment. Further, the ‘transitional occlusion’ is transfigured into a final
occlusion to establish a relationship amongst all teeth that are appropriately placed
in the jaw arcades and display a functional anatomic relationship to each other.
Ultimately, the dentition should exhibit a cusp-fossa relationship, to ensure struc-
tural durability, functional efficiency, and aesthetic harmony. The prerequisites of
transitional occlusion and its importance, along with biomechanical principles of
SFOA protocol, are explained in detail in Chaps. 4 and 5.
‘Paper and model surgery’ offers a simple and reliable method of assessing and
formulating the treatment plan of a dentofacial deformity using routinely available
tools of assessment such as photographs, study models, and radiographs (cephalo-
graphs). Meticulous evaluation of specific landmarks and planes can lead to
2.3 Conventional Jaw Surgery Planning: Paper Surgery and Model Surgery 11
Fig. 2.3 Figure showing gnathic profile field, rule of thirds, and preclinical measurement chart
used for the initial assessment of SFOA cases. GPF essentially involves certain landmarks which
are enumerated below: nasion (Na), the junction of the nasal and frontal bones at the most posterior
point on the curvature of the bridge of the nose; orbitale (Or), a point midway between the lowest
point on the inferior margin of the two orbits; pogonion (Pg), the most anterior point on the contour
of the chin; porion (Po), the midpoint of the upper contour of the external auditory canal (anatomic
porion) or a point midway between the top of the image of the left and right ear rods of the cepha-
lostat (machine porion); subnasale (Sn), it is the transition point between the nose and the upper
lip. It is the projection of hard tissue A point; Frankfort horizontal plane (FHP), a line connecting
Po to Or; OVL orbitale vertical line; NVL nasion vertical line
12 2 Diagnosis and Treatment Planning of Surgery-First Orthognathic Approach
Skeletal movements of jaw surgery are planned by analysing certain soft tissue
landmarks. Schwarz used these landmarks for photographic and clinical assess-
ment. We have adapted them to lateral cephalograph for the planning of jaw surgery.
Also, postero-anterior (PA) cephalographs are used to assess and plan jaw surgery
for the correction of skeletal asymmetry.
‘GPF’ and ‘rule of thirds’ provide simple and practical method of clinical evalu-
ation of the soft tissue relationship. The surgical splint produced using this method
involves the orthodontist in the splint fabrication, so that the orthodontist can con-
trol all the variables. Performing the ‘paper surgery’ and ‘model surgery’ aids the
surgeon to emulate the plan and to preview the final outcome (Fig. 2.4). The afore-
mentioned conventional jaw surgery approach poses several drawbacks at various
levels, and they are (1) 2D representation of a complex 3D maxillofacial structure,
(2) incorporation of cephalometric tracing errors during planning, (3) face-bow
transfer and dental model mounting errors, and (4) model surgery errors, surgical
splint fabrication-induced errors, and so on [9, 10].
3D virtual surgical planning (see Fig. 2.5) has brought newer insights and better
outcomes in the assessment of the maxillofacial complex surgery, especially offset-
ting the demerits of 2D modality of image acquisition and diagnosis. 3D imaging
modalities such as CBCT has expanded the diagnostic envelope and has become an
indispensable diagnostic aid as it has made possible to visualize intricate details of
the craniofacial structures as accurately as possible and to also enable cranial base
superimposition with a voxel-wise method. This has made it possible to analyse
structures such as temporomandibular joint and the extent to which craniofacial
structures respond during the post-surgical phase.
The individual treatment plan and execution will be discussed in the subsequent
relevant chapters.
Fig. 2.5 Summary of 3D-assisted SFOA treatment planning showing integration of CBCT
images, photogrammetry images, and intraoral scanner images for the creation of virtual compos-
ite model. Virtual planning software is used for the planning of surgery, and digital surgical splints
are created on the computer monitor. The digital splints are then transferred via stereolithography
file format to a 3D printer for the splint printing. The printed splints are used in the operating room
14 2 Diagnosis and Treatment Planning of Surgery-First Orthognathic Approach
2.5 Conclusion
Strategic planning will help you uncover your available options, set priorities for them, and
define the methods to achieve them.—Robert J. McKain
References
1. Sugawara J, Nagasaka H, Yamada S, Yokota S, Takahashi T, Nanda R. The application of orth-
odontic miniplates to sendai surgery first. Semin Orthod. 2018;24(1):17–36.
2. Nagasaka H, Sugawara J, Kawamura H, Nanda R. “Surgery first” skeletal Class III correction
using the Skeletal Anchorage System. J Clin Orthod. 2009;43:97.
3. Baek S-H, Ahn H-W, Kwon Y-H, Choi J-Y. Surgery-first approach in skeletal class III maloc-
clusion treated with 2-jaw surgery: evaluation of surgical movement and postoperative orth-
odontic treatment. J Craniofac Surg. 2010;21:332–8.
4. Hernández-Alfaro F, Guijarro-Martínez R, Molina-Coral A, Badía-Escriche C. “Surgery first”
in bimaxillary orthognathic surgery. J Oral Maxillofac Surg. 2011;69:e201–e7.
5. Hernández-Alfaro F, Guijarro-Martínez R, Peiró-Guijarro MA. Surgery first in orthognathic
surgery: what have we learned? A comprehensive workflow based on 45 consecutive cases. J
Oral Maxillofac Surg. 2014;72:376–90.
6. Kim J-Y, Jung H-D, Kim SY, Park H-S, Jung Y-S. Postoperative stability for surgery-first
approach using intraoral vertical ramus osteotomy: 12 month follow-up. Br J Oral Maxillofac
Surg. 2014;52:539–44.
7. Liou EJ, Chen P-H, Wang Y-C, Yu C-C, Huang C, Chen Y-R. Surgery-first accelerated orthog-
nathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg.
2011;69:771–80.
8. Yu C-C, Chen P-H, Liou E, Huang C-S, Chen Y-R. A surgery-first approach in surgical-
orthodontic treatment of mandibular prognathism—a case report. Chang Gung Med J.
2010;33:699–705.
9. Lin H-H, Lo L-J. Three-dimensional computer-assisted surgical simulation and intraoperative
navigation in orthognathic surgery: a literature review. J Formos Med Assoc. 2015;114:300–7.
10. Polley JW, Figueroa AA. Orthognathic positioning system: intraoperative system to transfer
virtual surgical plan to operating field during orthognathic surgery. J Oral Maxillofac Surg.
2013;71:911–20.
Biological Principles and Responses
to Surgery-First Orthognathic Approach 3
3.1 Introduction
Corticosteroids, Osteocalcin
Bisphosphonates,
Lipids, Local pH
Regional Acceleratory
Phenomenon (RAP)
Sub-Optimal
Spontaneous fractures
Non-Mechanical/Non-
Disorder Induced
Neoplasm
Ruptures
Arthoses
Physical
Skeletal Physiology Agents
Tissue-level Mechanisms
Optimal
• Growth modelling
• Maintenance
• Remodelling
Effector Cells
• Osteoblasts
• Osteoclasts
Sub-Optimal
Function Maintenance
Repairs Microdamage
Mechanical/Physical
Skeletal Health
Systemic Acceleratory
Phenomenon (SAP)
Optimal
Magnetic Fields and Laser
Micro-osteoperforations
Corticotomy/Osteotomy
Electric Currents, and
Temperature, Laser,
Loads, Strains
Piezoincision
Fig. 3.1 Different physiological agents (mechanical and nonmechanical) can invoke tissue-level
mechanisms that effect osteoblast and osteoclast cells. Re-establishment of a bone injury not only
leads to a RAP but also to a systemic acceleratory phenomenon (SAP). Optimal and suboptimal
levels of RAP and SAP induce different sets of reactions (skeletal health and disorder)
defence reactions. The study of growth and repair, and remodelling processes, sub-
sequently leads to an establishment of a ‘new paradigm’ for bone biology [1, 6].
RAP can be invoked by any noxious stimuli as enumerated in Figs. 3.1 and 3.2.
Once initiated, the BMU triggers a biological response, directly proportional to the
3.2 Regional Acceleratory Phenomenon 17
Circumferential vascular
Bradykinin, IL-1 α,4
ligament
Reactive Oxygen Species (ROS)
Platelet activating factors (PAF)
Arachidonic acid metabolites
Lysosomal component
Neuropeptide
Cell derived
Cytokines
Non-infection
Surgery intervention
catecholamine release
PG, NGF, SP, HIF-1α
Nervous system
TNFR1,R2
TLR1-9
IL-1R1
Chemical Mediators
Infection
RAP
Angiogenesis, Neovascularisation,
Perfusion, Proliferation,
VEGF, C3a,b; C5a,b
Mac-1,NO
PG-D,E,F
Complement activation C3a,b,5a,b
Injury
Fibrinolysis system
Plasma derived
Clotting system
Fractures
Kinin System
repair
Bone
Fig. 3.2 RAP is a ubiquitous phenomenon that not just solely occurs in the skeletal system but
also in the soft tissue, nervous system, and dental and periodontal ligament too, which is mediated
by various plasma- and cell-derived mediators. Several mediators have been identified that play a
direct or indirect role in the local and systemic acceleration of healing process. IL interleukin, OPG
osteoprotegerin, PDGF platelet-derived growth factor, TNF tumour necrosis factor, ICTP
C-terminal telopeptide of type I collagen, OSM oncostatin M, INF interferon, bALP bone alkaline
phosphatase, BMP bone morphogenetic proteins, DKK Dickkopf homologue, PG prostaglandin,
RANKL receptor activator of nuclear factor kappa-Β ligand, RUNX runt-related transcription fac-
tor, Cbf core binding factor, VEGF vascular endothelial growth factor, LT leukotriene, Mac macro-
phage-1, NO nitrogen oxide, IL interleukin, TNF tumour necrosis factor, TLR toll-like receptors,
NGF nerve growth factor, HIF hypoxia-inducible factor, SP specificity protein, CGRP calcitonin
gene-related peptide
18 3 Biological Principles and Responses to Surgery-First Orthognathic Approach
magnitude and nature of stimulus [3], which leads to the cascade of the cyclical
sequence of events of activation, resorption, and formation, commonly abbreviated
as ‘ARF sequence’.
Newer insights have unveiled the manner of tissue responses in corticotomy- and
osteotomy-assisted tooth movements. Dentoalveolar procedures (periodontal flap
surgery, exposure of palatally impacted canines, dental extractions), orthognathic
jaw surgery osteotomy, corticotomy, and distraction osteogenesis are capable of
altering the bone biology (increased activation of BMU).This subsequently
Table 3.1 The table illustrating key features of osteotomy and corticotomy procedures
Osteotomy Corticotomy
Definition Cutting through the cortical and Only cortical bone is cut to
trabecular bone to create a improve bony remodelling
completely separate alveolar [22]
segment [21]
Rate of tooth movement Peaks at 1–3 weeks after surgically Peaks at 3-week post-
induced trauma. Phenomenon lasts corticotomy. It lasts for 4
for 3–4 months postoperatively [23] months postoperatively [24]
Immunostaining Less osteopenia around dental roots More demineralization
assessment in comparison to corticotomy [15] (porosity) observed around
dental roots [15]
MicroCT assessment Distraction osteogenesis in the Regional accelerated
osteotomy-assisted tooth movement phenomenon was observed
is observed [12] in the alveolar bone [12]
Overall treatment time Up to 50%. Reduction [9, 21, 25, 26] Reduction of 28% and 70%
[9, 21, 25, 26]
Periodontal problems Non-detrimental effects [27–29] Non-detrimental effects
(probing depth, recession, [27–29]
attachment loss, or
bleeding on probing)
Root resorption No root resorption after surgically No root resorption [22, 30]
facilitated movement of teeth [22,
30]
3.4 Surgery-First Orthognathic Approach’s Molecular Response 19
SFOA utilizes the sudden surge of cyclical sequence of bone modelling and remodelling
events that ensues subsequent to osteotomy cuts made for the correction of jaw
deformity. The osteotomy-assisted tooth movement is thought to accelerate significantly
orthodontic tooth movement. It also reduces the total orthodontic treatment duration by
using the RAP period to facilitate the orthodontic treatment phase. Recently, literature
pertaining to relationship between corticotomy- and osteotomy- assisted tooth
movement suggests alveolar bone surrounding teeth experiences short-term osteopenia
or demineralization, especially at the corticotomy site.
Buschang and colleagues observe that corticotomies hasten tooth movements
because the ‘surgical insult’ produces RAP, and greater the injury, the more the
tooth movement. Also, they observed that RAP reduces the amount and density of
bone that the tooth has to traverse through. Hence, they concluded that ‘corticoto-
mies should be considered as stable, undisplaced fractures that injures the perios-
teum and bone’ [18, 19].
Liou et al. studied the postoperative changes in bone physiology and the
corresponding responses in the dentoalveolus in orthognathic surgery subjects. The
clinical study evaluated serum alkaline phosphatase (ALP) and C-terminal
telopeptide of type I collagen (ICTP) bone markers and correlated with tooth
mobility of maxillary and mandibular incisors using the Periotest method. The
study concluded that jaw osteotomy triggered a 3- to 4-month period of increased
osteoclastic activity and metabolic changes in the dentoalveolus postoperatively and
corresponding increase in tooth mobility in the evaluated teeth. This study showed
that temporary surge in ICTP (osteoclastic activity) and ALP (osteoblastic activity)
indicated a transient burst of bone activation, resorption, and formation. This study
also confirms the previous animal study that restoration of a local defect in a rat
20 3 Biological Principles and Responses to Surgery-First Orthognathic Approach
model not only leads to a regional acceleratory phenomenon (RAP) but also to a
systemic acceleratory phenomenon (SAP) at distant sites of the skeleton.
Zingler et al. in their prospective cohort study evaluated biological changes
using GCF markers. The GCF markers, such as IL-1 b, IL-6, TGF b 1-3, MMP-2,
and VEGF, were studied before and after SFOA, and Zingler et al. concluded that
bone remodelling factors levels are elevated, which is reminiscent to fracture
healing [20].
3.5 Conclusion
References
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paradigm). Bone. 1997;20:385–91.
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accompanies the regional acceleratory phenomenon (RAP) during healing of a bone defect in
the rat. J Bone Miner Res. 1991;6:401–10.
7. Mueller M, Schilling T, Minne HW, Ziegler R. Does immobilization influence the systemic
acceleratory phenomenon that accompanies local bone repair? J Bone Miner Res. 1992;7.
8. Schilling T, Mueller M, Minne HW, Ziegler R. Mineral apposition rate in rat cortical bone:
physiologic differences in different sites of the same tibia. J Bone Miner Res. 1992;7.
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impacted canines: a preliminary study. Angle Orthod. 2007;77:417–20.
References 21
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e1–8.
Biomechanical Principles of
Surgery-First Orthognathic Approach 4
4.1 Introduction
SFOA evaluation and planning have to be precise and require a meticulous step-by-
step approach from case assessment to planning and the final execution of the sur-
gery. In order to take cognizance of the dentofacial structures and their posed
complexities, orthodontists expend a plethora of 3D techniques and modalities,
such as 3D facial morphometrics, 3D non-contact laser scan, 3D cone beam com-
puted tomography (CBCT), stereolithography, 3D ultrasound holography, finite ele-
ment modelling, Moire topography, video imaging, and contour photography
[1–5].
Among the above-mentioned imaging modalities, CBCT is the most widely used
3D radiography technique which facilitates the capture of important dentofacial
structural details [6]. SFOA demands an in-depth understanding of dentofacial traits
and various rotational and translational movements, in order to establish a surgical
treatment objective (STO) [7]. The maxillo-mandibular complex (MMC) is like a
rigid body with six degrees of freedom in three-dimensional space having three
translation coordinate axes, namely, (1)sagittal, (2) transverse, and (3) vertical, and
three rotation axes (1) pitch, (2) roll, and (3) yaw [6–8] (Fig. 4.1).
Fig. 4.1 Figure (left and right) illustrating a rigid body’s movement in a three-dimensional space
with six degrees of freedom (translation—transverse, sagittal, and vertical) (rotation—pitch, roll,
and yaw)
Natural head position is the position of the head when the subject looks at a distant
point at eye level and their visual axis is parallel to the ground [9]. Xia et al. describe
a ‘global coordinate system’ comprising of local (maxilla, mandible, etc.) and
global (whole head) reference frames that form an essential system to determine the
facial configurations in both two and three dimensions [10]. In the past, several
methods have been attempted to reproduce NHP consistently as Cassi et al. noted
that NHP plays an important role when investigating the association between cra-
niocervical posture and dentofacial morphology. It also forms a postural basis for
assessment of craniofacial morphology [11]. Once the image is captured in NHP,
further, NHP proof images can be used to plan surgery in the six degrees of freedom
(6DoF). 6DoF refers to the freedom of movement of a rigid body in three-
dimensional space. Specifically, the body is free to alter spatial position as forward/
backward (longitudinal or sagittal), up/down (vertical), and left/right (transverse)
translation in three perpendicular axes. This is in combination with variations in
orientation through rotation about three perpendicular axes, termed as yaw (vertical
axis), pitch (transverse axis), and roll (longitudinal or sagittal or anteroposterior
axis) [8, 10] (Fig. 4.1).
4.2.1.1 Pitch
Pitch is defined as the body’s rotation fixed between the side-to-side axis (on a
patient’s right ear to left ear or left to right lip corners) also known as the lateral or
transverse axis. Pitch is referred as positive when the anterior segment is raised
upward and posterior segment is lowered (Fig. 4.1).
4.3 Considerations of Translational (Sagittal, Transverse, Vertical) and Rotational… 25
4.2.1.2 Roll
Roll is defined as the body’s rotation fixed between the front-to-back axis (on a
patient’s lip to back of head or ANS to PNS) also known as the longitudinal axis.
Roll is referred as positive when the left side is raised upward and the right segment
is lowered (Fig. 4.1).
4.2.1.3 Yaw
aw is defined as the body’s rotation fixed around the vertical axis (on a patient’s
superior border of calvaria to mandible base). Yaw is referred as positive when the
anterior segment moves to the right (Fig. 4.1).
Fig. 4.2 Figure depicting PA and lateral cephalograph tracings with reference planes and maxilla
and mandible templates for the depiction of paper surgery in the form of six degrees of freedom
translational and rotational movements of maxilla. Image (top extreme left) (Fig. 4.3)
shows ‘maxilla template’ with ‘five pivotal points’, which are located (1) distal to
PNS, (2) at PNS, (3) in between ANS-PNS, (4) at ANS, and (5) mesial to ANS and
are applied for maxilla pitch evaluation and correction. These aforementioned piv-
otal points are intended for the pitch correction and could be used in conjunction with
correction of translation deficiency. The yaw correction can be visualized in the max-
illary mounted cast and can be corrected accordingly (top extreme left) (Fig. 4.3).
Figure 4.4a, b is a case illustrating the application of traditional orthodontic
assessment tools in the planning of SFOA case with six degrees of freedom. The pre-
surgery cephalometric evaluation depicted the following aberrations: (1) maxilla,
hypoplastic (backward translation), anticlockwise tipping (positive pitching motion
with ANS raised and PNS lowered) with downward translation at the right canine,
and (2) mandible, hyperplastic (forward translation) and lateral translation (left side).
Surgical planning is done by placing maxilla template on the original tracing; the
maxilla is impacted for 3 mm at PNS and downward for 3 mm at ANS (clockwise
4.3 Considerations of Translational (Sagittal, Transverse, Vertical) and Rotational… 27
rotation, negative pitch) and advanced for 5 mm (forward translation). The mandible
is translated (transverse movement) to the right side. The vertical excess is corrected
by genioplasty (both sagittal and vertical translation correction).
The amount of rotation and translation movements would be confirmed during
the model surgery, and the surgical splints are created (Fig. 4.5). The maxilla was
moved according to the paper surgery planning and fixed to create the intermediate
splint by keeping mandible in its original position. Once the intermediate splint was
created, the mandible was moved as planned. Subsequently, the final surgical splint
is created.
The drawbacks of traditional analogue techniques would include (1) 2D represen-
tation of a complex 3D maxillofacial structure, (2) incorporation of cephalometric
tracing errors during planning, (3) face-bow transfer and dental model mounting
errors, and (4) model surgery errors and surgical splint acrylization errors [13]. If the
aforesaid shortcomings are controlled, then ‘paper and model surgery’ is beneficial
28 4 Biomechanical Principles of Surgery-First Orthognathic Approach
as it allows the clinician to utilize the routine tools of assessment without depending
on supplementary 3D imaging modalities.
Fig. 4.4 (a) Maxilla and mandible template and MMC movements in vertical and sagittal direc-
tions using lateral cephalograph. (b) Maxilla and mandible template and MMC movements in
vertical and transverse directions using postero-anterior cephalograph
4.3 Considerations of Translational (Sagittal, Transverse, Vertical) and Rotational… 29
Fig. 4.5 The planned paper surgery is simulated in the face-bow transfer articulator-mounted
models. The maxilla is advanced and moved downward at ANS, along with impaction at PNS (red
and yellow arrows). The mandible is set back to 6 mm. Enough clearance is provided (small red
arrows) between the surgical splint and brackets to avoid accidental dislodgement during surgery
30 4 Biomechanical Principles of Surgery-First Orthognathic Approach
Fig. 4.6 Pre-treatment images showing Class III facial profile with mandibular asymmetry
occlusion position. A three-point occlusal contact (two points of contact in the bilat-
eral posterior segment and one in the anterior segment) is ideal. Otherwise, effort
has to be made to produce at least two-point occlusal contacts bilaterally in the
posterior segment. A case (Figs. 4.6, 4.7, 4.8, 4.9, and 4.10) is described in order to
understand the pre-surgery complexities as determined with the aid of 3D imaging
and the computer-assisted surgery planning using SFOA.
A 3D pre-surgical evaluation showed a Class III malocclusion with maxillary
hypoplasia, maxillary cant, and mandibular prognathism with both maxilla and
mandible deviated to the left side. The treatment objective was to correct the hypo-
plastic maxilla and prognathic mandible, correct the left-sided shift, correct the
maxillary cant, and establish positive overbite.
The 3D evaluation showed maxillary cant with increased maxillary distance to
FHP on the right side in comparison to left side. It is very important to identify
whether the maxillary canting is due to dental issue or a skeletal issue or a combina-
tion of both. This discernment plays a vital role in the SFOA, as the teeth will not be
aligned prior to surgery, and this would compromise the treatment planning if not
evaluated appropriately [14, 15]. There are several ways of assessing the cant, and
these are (1) clinical assessment (refer to Chap. 2), (2) frontal cephalographs, and
(3) 3D morphometric assessment—surface-based and volume-based computed
shape measurements and (4) mirroring method [16–19] (Figs. 4.11 and 4.12).
4.3 Considerations of Translational (Sagittal, Transverse, Vertical) and Rotational… 31
a b c d
e f
g h
Fig. 4.7 Images showing both maxillary and mandibular facial asymmetry and 3D computer-
assisted planning. (a, b) Showing the pre-treatment skeletal discrepancy. (c–f) Image showing the
surgical planning by application of 6DoF movements; the maxillary skeletal movements are
planned with reference to FHP, and subsequently the mandible follows the maxilla’s planned posi-
tion whilst making sure that at least two-point occlusal contact is achieved. (g, h) In this case, a
three-point contact is established with two points in the posterior region bilaterally at second
molars and one point in the anterior region at incisal area
Fig. 4.8 Top images showing pre-treatment (left), predicted (middle), and post-surgery (right)
profile view. Bottom images showing intermediate (left) and final (right) surgical splints
32 4 Biomechanical Principles of Surgery-First Orthognathic Approach
Table 4.1 Table explaining the 6DoF movements in terms of rotational and translational move-
ment of the maxillo-mandibular complex
Rotation Translation
Pitch Roll Yaw Transverse Vertical Sagittal
Maxilla • Negative Negative roll Positive Right side • Downward Advancement
pitch at left canine yaw movement movement at at ANS
• Clockwise and left molar ANS
rotation • Impaction at
PNS
Mandible • Negative Negative roll Positive Right side Downward Set-back at
pitch at left canine yaw movement movement at pogonion
• Clockwise and left molar pogonion
rotation
34 4 Biomechanical Principles of Surgery-First Orthognathic Approach
4.4 Conclusion
The importance of recording the NHP along with the proper evaluation of maxillo-
mandibular complex in three dimensions with emphasis on 6DoF in both analogue
and 3D-assisted planning is key in the success of SFOA. Meticulous planning and
considerations of translational (sagittal, transverse, vertical) and rotational enve-
lopes (pitch, roll, and yaw) have to be considered in relation to the dentition and soft
tissue when planning for SFOA cases.
References
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2015;43:264–73.
8. Dorafshar AH, Brazio PS, Mundinger GS, Mohan R, Brown EN, Rodriguez ED. Found in
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9. Marcotte MR. Head posture and dentofacial proportions. Angle Orthod. 1981;51:208–13.
10. Xia J, Gateno J, Teichgraeber J, Yuan P, Li J, Chen K-C, et al. Algorithm for planning a double-
jaw orthognathic surgery using a computer-aided surgical simulation (CASS) protocol. Part 2:
three-dimensional cephalometry. Int J Oral Maxillofac Surg. 2015;44:1441–50.
11. Cassi D, De Biase C, Tonni I, Gandolfini M, Di Blasio A, Piancino M. Natural position of
the head: review of two-dimensional and three-dimensional methods of recording. Br J Oral
Maxillofac Surg. 2016;54:233–40.
12. Trpkova B, Prasad NG, Lam EW, Raboud D, Glover KE, Major PW. Assessment of facial
asymmetries from posteroanterior cephalograms: validity of reference lines. Am J Orthod
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13. Jeon J, Kim Y, Kim J, Kang H, Ji H, Son W. New bimaxillary orthognathic surgery plan-
ning and model surgery based on the concept of six degrees of freedom. Korean J Orthod.
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References 35
14. Im J, Kang SH, Lee JY, Kim MK, Kim JH. Surgery-first approach using a three-dimensional
virtual setup and surgical simulation for skeletal Class III correction. Korean J Orthod.
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15. Liou EJ, Chen P-H, Wang Y-C, Yu C-C, Huang C, Chen Y-R. Surgery-first accelerated orthog-
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Surgery-First Orthognathic Approach
Treatment Protocol: Orthodontic 5
Considerations
5.1 Introduction
All SFOA practitioners (both orthodontist and surgeons) have their own individual
technique and treatment philosophies that suit them as a team. No universal agree-
ment exists on the choice of orthodontic appliances; however, the guiding principles
of SFOA (i.e. minimal pre-surgical orthodontics) prevail. Table 5.1 illustrates differ-
ent treatment protocols, and Table 5.2 illustrates our treatment protocol on orth-
odontic preparation.
Several authors have reported placing fixed orthodontic bracket 1–6 weeks
before the scheduled surgery date with the objective of placing passive arch wires or
passively ligating the brackets with ligature wires [9, 11].
1. Bracket slot size: The most commonly used bracket slot sizes are 0.018″ × 0.025″
(0.46 × 0.64 mm) and 0.022″ × 0.028″ (0.56 × 0.7 mm). 0.022″ × 0.028″ bracket
slot allows the insertion of heavier arch wires making the levelling and aligning
easier.
2. Ligation of brackets: Engaging passive rectangular stainless steel wires
(0.017″ × 0.025″) in a 0.022″ × 0.028″ bracket slot could be done (Fig. 5.1);
however, the placement of passive rectangular surgical wire is time-consuming
and requires proficiency in making complex wire bends. Literature suggests
bonding arch wire directly on to the teeth for the technical ease of speeding the
pre-surgical procedure [3]. Post-surgically, this particular approach might pose
difficulty in debonding the wire and bonding brackets in a fairly uncomfortable
recovering patient [12]. The use of passive ligation of soft stainless steel ligature
wires around the bracket and the advantages of applying stainless steel ligature
wire are enumerated in the Table 5.2. A simple fix to this problem would be to
place arch wires just prior to surgery (24 h). This will allow orthodontic tooth
movement to start immediately post-surgery.
3. Surgical hooks: Kobayashi ligature hooks (K-hook) (0.012″ or 0.014″) (Fig. 5.2)
ligated around the bracket require no use of heavy or rigid arch wire (rectangular
arch wire), whereas the use of a crimpable surgical hook or a soldered hook
requires a rigid arch wire, thus making Kobayashi hooks not only easy to use but
often becomes the only option, especially in cases where the inter-bracket span
is markedly reduced (e.g. severe crowding).
Table 5.1 SFOA treatment protocols: pre-, during-, and post-SFOA
SFOA treatment protocols: pre-, during-, and post-SFOA
Pre-SFOA During SFOA Post-SFOA
Preoperative Orthodontic appliance Intermaxillary Orthodontic
Authors, orthodontic fixation treatment Type of elastics,
publication preparation duration andSurgical Transitional commencement duration, and Arch wire
year time Brackets Wires purpose splints occlusion post-surgery purpose sequencing
Nagasaka NR 0.022″ slot 0.018″ × 0.025″ Optimal
IMF to prevent Class III was 1 month Vertical elastics NiTi wires
et al. passive SS unwanted positioning overcorrected to to stabilize jaw Sequencing NR
(2009) [2] incisor and Class II position and
5.2 Pre-surgical Orthodontics
3/16″ 3/16″
(3.5 Oz/100 g) (3.5 Oz/100 g)
0.017″ × 0.025″ TMA low friction Impala Zebra Moose Moose
3/16″ (6 Oz/170 g) 5/16″(4.5 Oz/130 g) 5/16″ 5/16″ (6 Oz/170 g)
(6 Oz/170 g)
• Elastics: Full-time wear
Arch wire sequencing 0.014 NiTi/0.018″ Cu NiTi One week post-surgery for minor/moderate crowding alleviation
Upper and lower arch wires
0.016″ × 0.022″ NiTi Within ≤3 months post-surgery
Upper and lower arch wires
0.017″ × 0.025″ TMA low friction • With second-order bends and Class II/Class III elastics
Upper and lower arch wires • Cantilever mechanics
0.018″ SS/0.017″ × 0.025″ TMA low For settling of occlusion and finishing and detailing
friction
Upper and lower arch wires
0.21″ × 0.25″ TMA low friction/SS
Upper and lower arch wires
Adjunct appliances Chin cap can be applied to prevent the mandibular skeletal relapse in the first 3 months postoperatively
a
Ormco Corporation, Orange, CA, USA
43
44 5 Surgery-First Orthognathic Approach Treatment Protocol: Orthodontic…
Fig. 5.1 Images showing complex wire bending in order to adapt to the unresolved pre-treatment
tooth positions. This method of adapting heavy rectangular arch wires might provide enough
stiffness in the form of placement of surgical hooks directly on the rigid arch wire for the application
of surgical splint during surgery. However, it might be a time-consuming procedure that requires
dexterous clinician, and if the wire is not handled well, there is a potential to incorporate undesirable
torque in the wire. Typically, a (0.017 × 0.025″ or 0.018 × 0.025″ SS/TMA) rectangular wire is
annealed to minimise the wires yield and tensile strength, and increase its ductlity so that the wire
is soft enough for finger-pressure adaptaion and yet maintain rigidity to hold surgical hooks
Fig. 5.2 Image showing passive stainless steel ligature wires used to secure the brackets before
surgery (right side) and K-hooks ligated to the brackets. Post-surgery, K-hooks are utilized to hook
elastics
Several authors have termed the planned occlusion that is determined during model
surgery as the transitional occlusion (Figs. 5.3 and 5.4) [13], treatable malocclu-
sion [14], surgical temporary occlusion [9], or intended transitional occlusion
(ITM) [10]. The transitional occlusion is an occlusion that is set up immediately
after surgery such that the existing malocclusion lies within the orthodontically
manageable tooth movement boundary. Further, the ‘transitional occlusion’ could
5.3 Pre-surgical Preparation 45
Fig. 5.3 Images (top row) illustrating a skeletal Class III subject showing horizontal growth
pattern with deep curve of Spee. Images (middle row) showing a transitional occlusion are created
on articulator-mounted study models, wherein a three-point contact is established with two-point
contact on the bilateral second molars and one-point contact in the anterior teeth such that buccal
open bite is created. Subsequently, the buccal open bite is corrected postoperatively, thus correcting
the deep curve of Spee. Images (bottom row) showing immediate post-surgery, where the exact
planned transitional occlusion set-up is emulated in the surgery
Fig. 5.4 Images (top row) showing a skeletal Class III subject having moderate crowding, mild
anterior open bite, and a vertical growth pattern. A 3D surgery planning software (middle row) is
used to plan the transitional occlusion with a clockwise maxilla advancement and downward
movement and anticlockwise mandibular setback such that vertical excess is resolved and also
anterior open bite is corrected. Images (bottom row) showing final result immediately after
surgery
• Sagittal plane
–– For minimal or moderate crowding cases, establishing positive overjet or an
occlusion with three-point contact with two points contacting at the posterior
teeth preferably at bilateral molars and one point at the anterior teeth such that
a tripod effect is created [15]. The three-point contact with one point contact-
ing the anterior teeth should be attempted only if the inclination of the anterior
teeth is within normal limits. If the anteriors require correction (retroclined or
proclined), then it’s prudent to avoid using the anterior teeth for a three-point
contact and should resort to a two-point contact of bilateral posterior teeth.
–– For severely retroclined or crowded lower anterior teeth and proclined upper
anterior teeth cases, creation of larger positive overjet such that the large over-
jet can be utilized for lower incisors uprighting or decrowding and/or retrac-
tion of proclined upper incisors. A two-point contact of bilateral posterior
teeth should be attempted in the aforementioned scenario, as referencing the
anterior teeth will not be appropriate. Liao et al. recommended considering
extraction if the upper incisor to occlusion plane angulation is less than
53–55° [4, 16].
• Transverse plane
–– Intercanine and intermolar width of upper and lower dentition is maintained.
–– Crossbite not more than one buccal cusp width of maxillary molar.
• Vertical plane
–– For hypodivergent skeletal pattern with deep curve of Spee: edge-to-edge
anterior teeth with no occlusion in the posterior teeth such that posterior teeth
can be extruded post-surgically (Fig. 5.4).
–– For hyperdivergent skeletal pattern with anterior open bite: positive overjet
with clockwise rotation of maxilla and anticlockwise rotation of mandible to
counter post-surgical relapse of open bite (Fig. 5.5).
Merits
• Transitional occlusion model set-up permits evaluation of possibilities of
surgery-first orthognathic approach [9].
• Pre-surgical dental decompensation is avoided [13].
• Possible to ascertain post-surgical arch wire sequencing [9].
5.3 Pre-surgical Preparation 47
Fig. 5.5 A good fit of the surgical splints with enough clearance of the splint from the adjacent
brackets (red arrows) will prevent the splint from rocking and also avert brackets from debonding
by inadvertent force application during surgery
Demerits
• Both the surgeon and orthodontist require experience to visualize the post-
surgical transitional occlusion [13].
• Requires accurate prediction of the postoperative orthodontic treatment for
dental alignment, incisor decompensation, arch coordination, and occlusal set-
tling [9].
• The surgeon must be proficient at performing planned osteotomies with surgical
splint on dental arches with existing malocclusion and achieve required post-
surgical stability [14].
During the surgery, the orthodontist plays a key role, along with the surgeon, in the
determination of the surgical splints as well as the intermaxillary fixation manage-
ment. This section discusses the IMF and surgical splints indications, purpose, and
duration.
Different techniques to perform intermaxillary fixation (IMF), such as direct
interdental wiring, IMF screws, arch bars, eyelet wiring, and cap splints, are avail-
able [2, 4, 7, 8, 10–15, 17, 18]. IMF serves as a mode of immobilizing the jaw seg-
ments [2, 7, 12]. The objectives of minimizing the duration of the IMF and surgical
48 5 Surgery-First Orthognathic Approach Treatment Protocol: Orthodontic…
splint immediately after jaw surgery, instead of keeping it for several weeks, are as
follows:
Firstly, commence orthodontic tooth movement as soon as possible such that
regional acceleratory phenomenon can be utilized to the maximum. Secondly, the
rigid internal fixation, if done adequately, is sturdy enough to resist relapse which is
thought to occur due to premature occlusal interferences. Thirdly, if the IMF is left
for several weeks post-surgery, one must consider additional days of hospitalization
along with postoperative recovery issues such as assisted feeding and oral hygiene
deterioration.
5.4.2 P
ost-surgical Orthopaedic Management, i.e. Chin Cup
Therapy
Fig. 5.6 Images showing application of high pull chin cup immediately after surgery in a skeletal
Class III individual with excessive lower anterior face height
5.5 Conclusion
Acknowledgement The authors would like to thank Prof. Akshai Shetty, Department of
Orthodontics, RV Dental College, Bengaluru, Karnataka, India, for providing Fig. 5.1.
50 5 Surgery-First Orthognathic Approach Treatment Protocol: Orthodontic…
References
1. Park JH, Papademetriou M, Kwon Y-D, editors. Orthodontic considerations in orthognathic
surgery: Who does what, when, where and how? Seminars in Orthodontics. Amsterdam:
Elsevier; 2016.
2. Nagasaka H, Sugawara J, Kawamura H, Nanda R. “Surgery first” skeletal Class III correction
using the Skeletal Anchorage System. J Clin Orthod. 2009;43:97.
3. Baek S-H, Ahn H-W, Kwon Y-H, Choi J-Y. Surgery-first approach in skeletal class III
malocclusion treated with 2-jaw surgery: evaluation of surgical movement and postoperative
orthodontic treatment. J Craniofac Surg. 2010;21:332–8.
4. Liao Y-F, Chiu Y-T, Huang C-S, Ko EW-C, Chen Y-R. Presurgical orthodontics versus no
presurgical orthodontics: treatment outcome of surgical-orthodontic correction for skeletal
class III open bite. Plast Reconstr Surg. 2010;126:2074–83.
5. Villegas C, Uribe F, Sugawara J, Nanda R. Expedited correction of significant dentofacial
asymmetry using a “surgery first” approach. J Clin Orthod. 2010;44:97–103.
6. Uribe F, Janakiraman N, Shafer D, Nanda R. Three-dimensional cone-beam computed
tomography-based virtual treatment planning and fabrication of a surgical splint for asymmetric
patients: surgery first approach. Am J Orthod Dentofac Orthop. 2013;144:748–58.
7. Hernández-Alfaro F, Guijarro-Martínez R, Peiró-Guijarro MA. Surgery first in orthognathic
surgery: what have we learned? A comprehensive workflow based on 45 consecutive cases. J
Oral Maxillofac Surg. 2014;72:376–90.
8. Aristizábal JF, Martínez Smit R, Villegas C. The “surgery first” approach with passive self-
ligating brackets for expedited treatment of skeletal Class III malocclusion. J Clin Orthod.
2015;49:361–70.
9. Choi JW, Lee JY, Yang SJ, Koh KS. The reliability of a surgery-first orthognathic approach
without presurgical orthodontic treatment for skeletal class III dentofacial deformity. Ann Plast
Surg. 2015;74:333–41.
10. Yu H, Mao L, Wang X, Fang B, Shen S. The surgery-first approach in orthognathic surgery: a
retrospective study of 50 cases. Int J Oral Maxillofac Surg. 2015;44:1463–7.
11. Peiró-Guijarro MA, Guijarro-Martínez R, Hernández-Alfaro F. Surgery first in orthognathic
surgery: a systematic review of the literature. Am J Orthod Dentofac Orthop. 2016;149:448–62.
12. Kim JH, Mahdavie NN, Evans CA. Guidelines for “surgery first” orthodontic treatment.
Orthodontics-basic aspects and clinical considerations. InTech. 2012.
13. Liou EJ, Chen P-H, Wang Y-C, Yu C-C, Huang C, Chen Y-R. Surgery-first accelerated
orthognathic surgery: postoperative rapid orthodontic tooth movement. J Oral Maxillofac
Surg. 2011;69:781–5.
14. Huang C, Hsu S, Chen Y-R. Systematic review of the surgery-first approach in orthognathic
surgery. Biom J. 2014;37:184.
15. Gandedkar NH, Chng CK, Tan W. Surgery-first orthognathic approach case series: salient
features and guidelines. J Orthod Sci. 2016;5:35.
16. Kim J-Y, Jung H-D, Kim SY, Park H-S, Jung Y-S. Postoperative stability for surgery-first
approach using intraoral vertical ramus osteotomy: 12 month follow-up. Br J Oral Maxillofac
Surg. 2014;52:539–44.
17. Park H-M, Lee Y-K, Choi J-Y, Baek S-H. Maxillary incisor inclination of skeletal Class III
patients treated with extraction of the upper first premolars and two-jaw surgery: conventional
orthognathic surgery vs surgery-first approach. Angle Orthod. 2013;84:720–9.
18. Uribe F, Agarwal S, Shafer D, Nanda R. Increasing orthodontic and orthognathic surgery
treatment efficiency with a modified surgery-first approach. Am J Orthod Dentofac Orthop.
2015;148:838–48.
Surgical Management: Author’s
Surgery-First Treatment Protocol 6
6.1 Introduction
Several developments and refinements, over the years, with regard to (1) surgery
technique and approach, (2) fixation methods of osteotomy segment, and (3) gen-
eral surgical management, have made corrections of dentofacial deformity, with jaw
surgery an effective and predictable procedure with quality outcomes.
Every surgeon has a preferred technique and style of operation, and the surgical
technique per se, in SFOA, does not differ much in comparison to conventional
surgery. Hence, the routine planning involving conventional jaw surgery should be
followed for SFOA as well, along with additional considerations, and they are:
Pelo et al. conducted a systematic review to assess the risks in surgery-first orthog-
nathic approach and, in particular, focusing on the complications of segmental oste-
otomies of the jaws. Their study concluded that the risks associated with SFOA
segmental osteotomies are similar in nature as compared to conventional jaw surgery,
but also concluded that due to lack of studies on SFOA-related osteotomy complica-
tions, the risk associated with SFOA appears higher than with conventional surgery.
They also noted that the aforementioned observation could be due to a smaller num-
ber of SFOA studies which could lead to an exaggeration of the findings, and studies
with larger sample sizes would be required to confirm the findings [1].
Table 6.1 describes the different types of surgery with indications, complications,
considerations, and stability.
Table 6.1 Table illustrating the type of surgery with indications, complications, considerations,
and stability [2–6]
Surgical
technique Indications Complications Considerations Stability
LeFort • Plethora of • Posterior bony • Complete posterior • Bone grafts
osteotomy maxillary interferences bone trimming assist in the
spatial preventing desired • Allow appropriate healing and
corrections positioning and condylar seating long-term
involving resultant posterior • Allow soft tissue stability of
one-piece or occlusal premature releases to reduce soft LeFort
multipiece contacts tissue tension osteotomies
osteotomies • Improper
• Auto- and condylar positioning
anticlockwise during fixation
rotation of the leading to
maxilla immediate relapse
BSSO • Mandibular • Pterygomasseteric • Cortical bone • Use of lag
sagittal split advancement sling stripping thickness should be screw fixation
ramus and setback • Intraoperative considered
osteotomy • Auto- and bleeding • Extraction of
anticlockwise • Inferior alveolar impacted third molar
rotation of the nerve damage prior to surgery
mandible • Interferences of • Use of lag screw
proximal and distal • Maxillo-mandibular
segments during training elastics until
large setbacks primary healing period
• Torqueing of (about 10 days
segments during post-surgery)
fixation leading to • The distal portion of
‘condylar sagging’ proximal segment
requiring trimming to
avoid interferences
• Avoidance of
torqueing of segments
(continued)
6.2 Type of Surgery with Indications, Complications, Considerations and Stability... 53
Table 6.1 (continued)
Surgical
technique Indications Complications Considerations Stability
Inverted ‘L’ • Mandibular • Dead space is • Bone grafting is • Rigid
osteotomy advancement created between the required to fill the fixation is
and ramus bony gaps while space created during recommended
vertical advancing the advancement
lengthening mandible
• Rotate or • Temporalis
reposition the muscle attachment
mandible acts as a hindrance
posteriorly for advancement
with
asymmetry
Vertical • Amount of • Unseating of the • Coronoid processes • Rigid
ramus mandibular condyle in the might hinder large fixation is
osteotomy advancement glenoid fossa advancement as it recommended
and vertical • ‘Condylar interferes on the
lengthening sagging’ leading to zygomatic arch
possible immediate • Temporalis muscle
• Rotate or postoperative stretch should be
reposition the occlusal discrepancy considered
mandible • Consider
posteriorly coronoidectomy if
with large advancement is
asymmetry required
• Secondary • Consider minimal
correction of medial pterygoid
prior SSRO stripping for proper
failures seating of condyle in
glenoid fossa
Subapical • Segmental • Inferior alveolar • Inferior alveolar • Wearing of
osteotomies/ discrepancies nerve damage nerve and mental occlusal splint
interdental in the • Mental branches foramen must be along with
osteotomies occlusion damage identified and plates is
• Supra- or • Non-vitality of preserved recommended
infra-eruption the teeth • Teeth root position
of teeth and avoid dehiscence
requiring and fenestration
dentoalveolar • Consider
repositioning re-approximation of
• Bimaxillary the mentalis muscles
protrusion.
Genioplasty • Adjunct to • Non-vitality of • Horizontal cut • Genioplasty
en bloc or the teeth should be at least 5 mm segments
segmental • Lack of blood below the teeth apices stabilized with
osteotomies or supply • The final outcome plates are more
in isolation to • Mental nerve must be visualized stable
enhance the damage either during the
surgery • Failure to achieve surgery planning phase
outcome cosmetic objectives or during the surgery
• Preservation of
lingual blood supply
54 6 Surgical Management: Author’s Surgery-First Treatment Protocol
6.3 Conclusion
Success of SFOA relies on a close working relationship between the surgeon and
the orthodontist, from planning to execution to postoperative follow-up. Both the
orthodontist and the surgeon should have profound understanding of each other’s
capabilities and limitations of the specialities and to work on the strength of the
other to ultimately accomplish a highly predictable, safe, and desirable patient
outcome.
References
1. Pelo S, Saponaro G, Patini R, Staderini E, Giordano A, Gasparini G, et al. Risks in surgery-
first orthognathic approach: complications of segmental osteotomies of the jaws. A systematic
review. Eur Rev Med Pharmacol Sci. 2017;21(1):4–12.
2. Al-Moraissi EA, Ellis E. Is there a difference in stability or neurosensory function between
bilateral sagittal split ramus osteotomy and intraoral vertical ramus osteotomy for mandibular
setback? J Oral Maxillofac Surg. 2015;73(7):1360–71.
3. Mihalik CA, Proffit WR, Phillips C. Long-term follow-up of Class II adults treated with orth-
odontic camouflage: a comparison with orthognathic surgery outcomes. Am J Orthod Dentofac
Orthop. 2003;123(3):266–78.
4. Proffit WR, Turvey TA, Phillips C. The hierarchy of stability and predictability in orthognathic
surgery with rigid fixation: an update and extension. Head Face Med. 2007;3(1):21.
5. Wolford LM, Spiro CK, Mehra P. Considerations for orthognathic surgery during growth, part
1: mandibular deformities. Am J Orthod Dentofac Orthop. 2001;19:95–101.
6. Greenberg AM, Prein J. Craniomaxillofacial reconstructive and corrective bone surgery prin-
ciples of internal fixation using the AO/ASIF technique. New York: Springer; 2002.
Management of Skeletal Class I
Malocclusion with Surgery-First 7
Orthognathic Approach
7.1 Introduction
The factors to be considered when performing these surgeries would be (1) the
extent of surgical movement required for the correction of the complexity and also
(2) the amount of extraction space utilization especially created during anterior seg-
mental osteotomy surgery.
Segmental osteotomy is primarily indicated when the discrepancy is defined by
the following conditions:
1. Dental proclination requiring extraction space for the correction of anterior teeth
inclination.
2. Moderate to severe crowding requiring extraction space for unravelling of
crowding.
Fig. 7.1 Figure describing possible surgery options available for the resolution of skeletal Class I sagittal discrepancy
7 Management of Skeletal Class I Malocclusion with Surgery-First Orthognathic…
7.3 Case Report 57
A 20-year-old female presented with a chief complaint of unable to see her top front
teeth when smiling. Extra-orally, she showed a concave profile, prominent chin,
retrusive upper and lower lip, and a reverse smile arc (Fig. 7.2). Intra-orally, she
showed a Class I molar and canine relationship and mild lower anterior crowding
with overjet and overbite within normal limits (Fig. 7.3). Cone beam computed
tomography scan (CBCT) confirmed the clinical findings (Fig. 7.4).
The objectives were classified into three main categories, and they are:
1. Skeletal objectives.
(a) To correct the hypoplastic maxilla.
(b) To correct the retrognathic mandible.
(c) To correct the large chin.
2. Dental objectives.
(a) To correct minimal crowding.
(b) To maintain the upper and lower arch Class I relationship.
3. Soft tissue objectives.
(a) To restore facial harmony.
(b) To produce an aesthetically satisfactory face.
Based on the clinical presentation and CBCT scan assessment, SFOA was planned
for the correction of maxillo-mandibular complex (Figs. 7.5 and 7.6). A LeFort I
osteotomy for the advancement of maxilla with clockwise rotation, and BSSO for
the advancement of the mandible, was planned, along with a reduction genioplasty
for the correction of the prominent chin.
All teeth were bonded, and a stainless steel ligature was tied passively in the upper
and lower arches. The patient was subjected to surgery as planned. One week post-
surgery extra-oral images showed fulfilment of surgery objectives with no change in
7.3 Case Report 59
Fig. 7.5 Extra- and intra-oral images taken just before surgery. Note: the brackets are ligated with
a non-active ligature wire
Fig. 7.6 Surgical plan; clockwise rotation of the maxillo-mandibular complex having pivotal
point in the middle of palatal plane (ANS to PNS) with advancement of the maxilla and mandible.
Also, genioplasty was done to reduce the protrusive chin
the occlusal aspect (Fig. 7.7). The overall treatment time was 4 months from start to
finish. Treatment results: post-treatment images (Fig. 7.8) and radiographs (Fig. 7.9)
showed excellent aesthetic and occlusal results (Fig. 7.9).
60 7 Management of Skeletal Class I Malocclusion with Surgery-First Orthognathic…
Fig. 7.7 Images taken at 1-week post-surgery showing fulfilment of surgery treatment objective
7.4 Conclusion 61
Fig. 7.8 Post-treatment images showing pleasing outcome with stable results
Fig. 7.9 Post-treatment lateral cephalograph and orthopantomograph showing stable results
7.4 Conclusion
This chapter describes the skeletal Class I deformity treated with SFOA with inten-
tion to maintain the pre-treatment occlusion relationship. The key for successful
management of skeletal deformity with Class I occlusion is to maintain the posterior
buccal occlusion; every effort should be made to preserve the occlusion.
Management of Skeletal Class II
Malocclusion with Surgery-First 8
Orthognathic Approach
8.1 Introduction
To correct crossbite
Skeletal cross bite ≤ postoperatively
molar width
Cross bite
Set-up occlusion Consider using TPA
3-piece Le Fort I osteotomy
SFOA Skeletal cross bite > within the tooth to correct bite
of the maxilla.
Treatment transverse molar width movement envelope post-operatively
Guidelines
Set-up occlusion
Edge-to-edge incisor
BSSO advancement and establish
moderate to deep Intrude anterior
posterior disocclusion teeth and allow
mandibular curve
of Spee eruption of posterior
teeth
Lower anterior Set-up occlusion in
segmental intrusion Class I relationship
Vertical
Differential impaction of
Set-up occlusion in Intrude posterior
Anterior open bite maxilla with clockwise
Class I relationship teeth, consider TAD’s
rotation + BSSO
advancement
Fig. 8.1 SFOA treatment guidelines in three dimensions based on the degree of complexity
8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
8.1 Introduction 65
Fig. 8.2 Images illustrating surgical orthodontics in skeletal Class II predominantly defined by
mandibular retrognathism (left side image). The Class II can be corrected by two ways: (1) straight
advancement of the mandible alone (middle image) which could be done in a moderate Class II
case requiring limited amount of mandibular advancement and (2) (right side image) counterclock-
wise rotation of MMC in severe retrognathic cases for achieving large amount of advancement,
enhancing chin projection, and improving pharyngeal airway space
Fig. 8.3 Images illustrating surgical orthodontics in skeletal Class II with mandibular retrogna-
thism, with deep bite and exaggerated curve of Spee. Perform counterclockwise rotation of man-
dible, and set up the bite in an edge-to-edge incisor relationship with posterior open bite.
Postoperative intrusion of lower incisors for further counterclockwise rotation of mandible is done
by cantilever arm mechanism with bilateral intrusion arms placed in the lower arch. The aforemen-
tioned mechanism will compensate for the post-surgery skeletal relapse with extrusion of upper
and lower posterior teeth and also allows to maintain the vertical height achieved by jaw surgery
66 8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
Fig. 8.4 Surgical orthodontics in Class II mandibular retrognathism. Setting up the mandible in
Class III and extraction of lower first premolars with anterior segmental osteotomy. The remaining
extraction space could be utilized for orthodontic retraction. However, extraction of first premolars
and anterior segmental osteotomy could produce periodontal problems such as fenestration and
dehiscence at the segmental osteotomy site and, also, with no antagonist teeth at the posterior seg-
ment might lead to supraeruption of unopposed upper molar tooth leading to further periodontal
and occlusion problems
Case 1: A 26-year-old female presented with chief complaint of small chin and
sticking out upper front teeth. She had orthodontic treatment during her teenage
years and expressed dissatisfaction with the results. On examination, she showed
short chin throat length, lip incompetence, a gummy smile, concordant smile arc,
missing #14, 24, and 34, and a lower dental midline deviated to the left side by
2 mm in relation to the upper dental midline. Her upper anterior teeth were retro-
clined, and pharyngeal airway space was constricted. The cephalometric findings
confirmed the clinical observation with SNA 77°, SNB 67°, ANB 10°, SN-MP 58°,
UAFH/LAFH 42/58%, U1/SN 85°, and IMPA 87°.
Two-jaw surgery: Counterclockwise rotation of MMC differential LeFort I oste-
otomy and BSSO. For LeFort I, the pivotal point is at the anterior maxilla with
superior repositioning of the anterior maxilla and inferiorly repositioning the poste-
rior maxilla such that the MMC rotates in a counterclockwise direction. (Refer to
Chap. 4 that explains further on pivotal points and advancement genioplasty.) The
MMC counterclockwise rotation would upright the upper incisor angulation and a
post-surgical occlusion set up in an anterior edge-to-edge relation with the remain-
ing midline discrepancy that would be corrected in the post-surgical orthodontic
treatment phase (Figs. 8.5, 8.6, 8.7, 8.8, and 8.9).
Case 2: A 22-year-old female presented with a chief complaint of her upper front
teeth forwardly placed and difficulty in eating with her front teeth. Extra-orally, she
exhibited a convex profile, marked protrusion of upper lip, and reduced lower ante-
rior facial height. Intra-orally, she showed 100% deep bite, Class II canine, and
molar relationship. CBCT scan confirmed the clinical findings with skeletal pattern
being hypodivergent and no temporomandibular joint aberrations.
Two-jaw surgery: A two-jaw surgery was planned such that mandible was
advanced to edge-to-edge bite with the creation of posterior open bite. LeFort I
8.2 Treatment of Various Skeletal Class II Cases 67
Fig. 8.6 Two-jaw surgery with counterclockwise rotation of MMC was planned. Refer text for
further explanation
68 8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
Fig. 8.7 (First and second row) Post-surgery lateral cephalograph and intra-oral photos showing
achievement of surgery objective. (Third row) 1-week post-op, minor early relapse was noted with
anterior overbite of −2 mm and overjet of 0 mm. (Fourth row) At 8-month post-op, midline and
anterior open bites were corrected by diagonal elastics and anterior vertical elastics, respectively
osteotomy with maxillary setback was planned for the correction of maxillary skel-
etal protrusion and also creation of an orthodontically treatable malocclusion
(Figs. 8.10, 8.11, 8.12, 8.13, 8.14, and 8.15).
Case 3: A 28-year-old female presented with a chief complaint of skewed upper
front teeth. Extra-orally, she showed convex profile, recessive chin with chin puck-
ering, asymmetric mandible with left side deviation, deep labial-mental fold, and an
asymmetric smile. Intra-orally, there were a left-sided buccal segment buccal cross-
bite and heavily restored upper and lower posterior teeth with maxillary occlusal
canting.
Two-jaw surgery: The mandible was advanced to edge-to-edge bite, and a LeFort
I, three-piece osteotomy was planned for the correction of maxillary skeletal protru-
sion and also for the buccal crossbite correction. This created an orthodontically
treatable malocclusion post-surgery (Figs. 8.16, 8.17, 8.18, 8.19, 8.20, 8.21, and
8.22).
8.2 Treatment of Various Skeletal Class II Cases 69
Fig. 8.8 (Top row) Pre-treatment and 1-week post-treatment CBCT superimposition showing
MMC counterclockwise rotation and genioplasty with anterior impaction of maxilla and counter-
clockwise rotation of maxilla, mandibular lengthening, and decreasing of gonial angle. (Middle
row) 1-week post-surgery superimposed on post-treatment showing 2-mm relapse at chin point
and extrusion of upper and lower dentition. Pre- and post-treatment superimposition CBCT showed
slightly forward movement of maxilla, 15-mm mandible advancement, upright and intruded upper
anterior teeth, extrusion of upper posterior teeth and lower anterior teeth
70 8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
Fig. 8.11 Planning is carried out such that a treatable malocclusion is established along with
mandibular advancement and counterclockwise rotation of MMC. An edge-to-edge incisor rela-
tionship with 7-mm posterior open bite is created in the study models. The surgery plan is emu-
lated with intra-oral images taken immediately post-surgery showing actualization of model
surgery
72 8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
Fig. 8.12 Images taken at 2 months post-surgery. Bilateral intrusion arches were placed in the
lower arch to intrude and upright the retroclined lower incisors. The cantilever mechanism will
extrude the posterior teeth and intrude and upright the anterior teeth. The aforementioned tooth
movement biomechanics is beneficial in this case, as the posterior teeth extrusion allows to close
the posterior open bite and maintain the vertical height established during surgery, and also, in the
anterior segment, intrusion and uprighting of anterior teeth will allow the mandible to further rotate
in anticlockwise direction which will enhance the chin projection and ultimately aid in improve-
ment of recessive chin
8.2 Treatment of Various Skeletal Class II Cases 73
Fig. 8.14 Images taken at 8 months post-surgery showing fulfilment of treatment objectives
Fig. 8.13 Images at 6 months post-surgery. Vertical elastics were placed for settling of occlusion
74 8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
Fig. 8.15 (Top row) Pre-treatment and 1-week post-treatment CBCT superimposition showing
advancement of the mandible as planned. (Middle row) Superimposition of 1-week post-surgery
with post-treatment CBCT scans showing extrusion of posterior teeth. (Bottom row) Images of
pre-treatment with post-treatment scans showing stable mandibular advancement (7 mm) and
genioplasty (5 mm) (total of 12-mm advancement), maxillary setback, and extrusion of posterior
teeth
8.2 Treatment of Various Skeletal Class II Cases 75
Fig. 8.16 Pre-treatment images showing Class II maxillary protrusion, mandibular retrognathism,
and facial asymmetry. Intra-oral images showing Class II division 1 malocclusion, left side buccal
segment scissors bite, heavy restorations of upper and lower posterior teeth. Maxillary occlusion
showed maxillary right side up occlusal cant, and mandibular occlusion showed left side up
76 8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
Fig. 8.17 The surgical plan included LeFort I three-piece osteotomy to decrease upper intermolar
width for the correction of left posterior segment scissors bite with extraction of bilateral upper
right and left second premolars. BSSO for mandibular advancement and counterclockwise rotation
with 2–3-mm posterior open bite. Note the maxilla is moved upward (crossed black lines) on the
left side for the correction of maxillary occlusal canting
8.2 Treatment of Various Skeletal Class II Cases 77
Fig. 8.19 Superimposition of pre-treatment and post-1-week CBCT images showing mandibular
advancement and genioplasty of 10 mm. Also, levelling of the upper and lower occlusion, and the
chin moved to the right. In addition to LeFort I setback and impaction, lengthening of mandible
and genioplasty was achieved. Note the occlusion on the left side is moved up and more mandibu-
lar lengthening on the left
8.2 Treatment of Various Skeletal Class II Cases 79
Fig. 8.20 (Top row) Images showing 1-month post-surgery images with lower anterior intrusion
carried out by bilateral intrusion arms. (Middle row) Images taken at 4-month post-surgery show-
ing placement of TAD in the lower left segment for lower left second molar protraction in the
extraction space. (Bottom row) Images showing settling elastics
80 8 Management of Skeletal Class II Malocclusion with Surgery-First Orthognathic…
Fig. 8.22 One-week post-surgery CBCT images superimposition over pre-treatment images
showing forward movement and upward rotation of mandible. One-week post-surgery CBCT
images superimposed over post-treatment showed forward rotation of mandible, slightly right
movement of mandible, extrusion of posterior teeth, and intrusion of lower anterior teeth with no
mandibular relapse. Pre-surgery and post-surgery CBCT superimposition images showing 12-mm
mandibular advancement and genioplasty with intrusion and retraction of anterior teeth
8.3 Conclusion
was not able to resolve. Case 2 presents with a skeletal Class II with a severe
deep bite and decreased lower facial height. No extractions were indicated, and
the surgery was planned to correct the irregularity by the surgery alone. Case 3
is a composite of dental and skeletal problems further worsened by a mutilated
dentition. The buccal crossbite was corrected by a three-piece LeFort I osteot-
omy with extractions of the upper first bicuspids. This allowed both the buccal
crossbite and the maxillary protrusion to be addressed by the surgery. A thorough
periodontal evaluation is imperative when contemplating intra-dental osteotomy
to prevent untoward sequelae, like fenestrations and dehiscence from occurring.
TAD was placed for the protraction of lower left second molar.
2. Skeletal considerations: Correction of skeletal Class II division 1 via surgery
requires appropriate surgery design/planning (encompassing a greater expanse
of problem list). (A complete list of do’s and don’ts is enumerated in Chap. 6.)
3. Soft tissue considerations: Lower lip position or entrapment, influence of coun-
terclockwise rotation on pterygomasseteric sling, and the role of post-surgery
occlusion on re-establishing soft issue harmony, neutral space, and on stability
need to be addressed (refer to Chap. 6).
Management of Skeletal Class III
Malocclusion with Surgery-First 9
Orthognathic Approach
9.1 Introduction
This chapter describes the nuances involved in the management of Class III skeletal
individuals treated with surgery-first orthognathic approach. Several factors have to
be taken into account for the successful management of Class III cases that are sub-
jected to SFOA without compromising on the final outcome. It is imperative that the
orthodontist and surgeon involved in SFOA should closely follow the orthognathic
surgery principles and also understand the limitations of orthodontic teeth move-
ment. The chapter’s focus is on treatment guidelines for Class III skeletal malocclu-
sion in three dimensions.
Figure 9.1 describes SFOA treatment guidelines in three dimensions based on the
degree of complexity. Three cases will be discussed in this chapter with moderate to
severe forms of Class III skeletal patterns. After initial evaluation with the essential
tools of assessment (refer to Chap. 2), a problem list is developed from a treatment
plan based on SFOA principles.
All three individuals displayed varying degree of skeletal Class III deformity. On
clinical examination, Case 1 showed concave profile, increased lower anterior face
height, hyperdivergent skeletal pattern, and a large mandible. Intraorally, Case 1
exhibited a Class III molar and canine relation, mild crowding of upper and lower
anterior teeth, dental midlines matching, and reverse overjet of 3 mm. A cone beam
computed tomography scan (CBCT) reveals the absence of skeletal asymmetry and
no abnormality of the temporomandibular joint.
Case 2, on clinical examination, revealed concave profile, severe Class III profile
with increased lower anterior face height, shallow mentolabial sulcus, and a positive
lip step. Intraorally, she showed severe crowding of upper and lower arch with
bimaxillary proclination of teeth. Whereas, Case 3 demonstrated a very severe form
of skeletal Class III with extremely hypoplastic maxilla, a large mandible, and exces-
sive lower anterior face height. Also, intraorally, he demonstrated a severe anterior
open bite with retroclined and crowded lower incisors and collapsed upper arch.
The treatment objectives were classified into three main categories, and they are:
1. Skeletal objectives.
(a) To correct the hypoplastic maxilla.
(b) To normalize the prognathic mandible.
2. Dental objectives.
(a) To upright the retroclined lower anterior teeth (in Cases 1 and 3).
(b) To retract proclined upper and lower anterior teeth (in Case 2).
(c) To correct a severely collapsed upper arch.
(d) To alleviate upper and lower arch crowding.
3. Soft tissue objectives.
(a) To restore facial harmony.
(b) To produce an aesthetically satisfactory face.
9.3.1 Treatment
9.3.1.1 Case 1
See Figs. 9.2, 9.3, 9.4, 9.5, 9.6, 9.7, 9.8, 9.9, 9.10, 9.11, 9.12, and 9.13.
9.3.1.2 Case 2
See Figs. 9.14, 9.15, 9.16, 9.17, 9.18, 9.19, and 9.20.
9.3.1.3 Case 3
See Figs. 9.21, 9.22, 9.23, 9.24, 9.25, 9.26, 9.27, 9.28 and 9.29.
9.3 Case Presentation 85
moderate
retroclined lower segmental osteotony + BSSO
+ set-back
crowded lower incisors Align lower incisors
Set-up occlusion in Utilizibg the large
Class I relationship overjet
Predined Lefort losteotony with
Sagittal clockwise rotation +
maxillary incisors
BSSO set-back
To correct crossbite
Skeletal cross bite ≤ postoperatively
molar width
Cross bite
Set-up occlusion Consider using TPA
3-piece Le Fort I osteotomy
SFOA Skeletal cross bite > within the tooth to correct bite
of the maxilla.
Treatment transverse molar width movement envelope post-operatively
Guidelines
Vertical
Differential impaction of
Set-up occlusion in Intrude posterior
Anterior open bite maxilla with clockwise
Class I relationship teeth, consider TAD’s
rotation + BSSO
advancement
Fig. 9.1 SFOA treatment guidelines in three dimensions based on the degree of complexity
Fig. 9.2 (Case 1) Initial images showing pre-treatment extra- and intra-oral photos of a female
with Class III prognathic profile, Class III molar relationship, and moderate crowding in the upper
and lower arch
86 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.3 Images showing intra- and extra-oral photographs just before surgery. Note, in this case,
all four first premolars were extracted during the bonding appointment (1 week before the
surgery)
9.3 Case Presentation 87
Fig. 9.4 CBCT scan and 3D photogrammetry images confirmed the clinical assessment clearly
showing mandibular prognathism and increased lower anterior face height. Further, these images
were used for 3D surgery planning
88 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.5 The final 3D prediction showing improved facial features along with establishment of
orthodontically manageable malocclusion
9.3 Case Presentation 89
Fig. 9.6 Images showing establishment of two-point contact in the posterior region. Also, note the
bilateral molar crossbite (post-treatment planning) is within the envelope of orthodontically treat-
able malocclusion
90 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.7 Images showing both maxillary and mandibular surgery planning done with the assis-
tance of ‘3D Surgery Planning’ software. By applying 6DoF movements, the maxilla is fixed with
reference to FHP, and subsequently the mandible is allowed to follow the maxilla’s planned posi-
tion whilst making sure that at least two-point occlusal contact is achieved. In this case, a two-point
contact is established with two points in the posterior region bilaterally at second molars, whilst at
incisal area, no attempt was made to establish contact due to extreme instanding upper lateral inci-
sors. In the anterior region, provisions were made such that the upper lateral incisor was in positive
overjet relationship
9.3 Case Presentation 91
Fig. 9.9 Images showing intra- and extra-oral photographs taken 1-week post-surgery. The
planned 3D surgical simulation is successfully emulated in the patient. All the objectives of SFOA
as enumerated in the text have been successfully achieved with minimal facial swelling. Anterior
box elastics, posterior bilateral Class III, and vertical configuration settling elastics were placed
immediately after the surgery in the operation theatre itself. Proper instructions were provided to
the patient for the placement of the same. Note the elastics were placed on K-hooks with ligature
wires in the upper and lower arches
Fig. 9.10 Images taken at seventh day post-surgery; the ligature wires were replaced with 0.016″
NiTi upper and lower arch wires
9.3 Case Presentation 93
Fig. 9.11 Nine months post-surgery, rectangular 0.017″ × 0.025″ TMA wires were placed in the
upper and lower arches. Intra- and extra-oral photographs showing Class I molar and canine rela-
tionships along with the resolution of both skeletal and dental problems
Fig. 9.12 Intra- and extra-oral photographs showing post-treatment images with a balanced face
and excellent Class I molar and canine relationship
94 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.13 Post-treatment CBCT images showing orthognathic skeletal relationship with normal
occlusion
9.3 Case Presentation 95
Fig. 9.14 Initial images showing pre-treatment extra- and intra-oral photos of a female with Class
III prognathic profile, Class III molar relationship, severe crowding, and bimaxillary proclination
in the upper and lower arch
96 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.15 A bijaw surgery was planned using ‘3D surgery planning software’. A mandibular set-
back sagittal split osteotomy along with maxillary LeFort I advancement surgery was planned
taking into account the 6DoF essential to resolve the skeletal problems associated with this patient
Fig. 9.16 Immediate post-surgery CBCT images showing orthognathic skeletal relationship
establishment. However, the proclination of upper and lower incisors and severe crowding still
need to be resolved; therefore, first bicuspid extractions were planned
9.3 Case Presentation 97
Fig. 9.17 Images showing intra- and extra-oral photographs of patient at 8 months post-surgery.
0.017″ × 0.25″ TMA upper and lower arch wires are placed after the resolution of crowding. Note,
the patient is ready for retraction of upper and lower anterior teeth
Fig. 9.18 At 18 months post-surgery, 0.017″ × 0.025″ SS upper and lower arch wires are placed. The
proclination of upper and lower anterior teeth are corrected, along with completion of space closure
98 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.19 Intra- and extra-oral photographs showing post-treatment images with a balanced face
and excellent Class I molar and canine relationship
Fig. 9.20 Post-treatment CBCT images showing orthognathic skeletal relationship with normal
occlusion
9.3 Case Presentation 99
Fig. 9.21 Initial images of a very severe Class III skeletal patient with severe anterior open bite,
retroclined and crowded lower incisors
Fig. 9.22 Upper and lower 0.014″ NiTi wires were placed in the upper and lower arch
100 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.23 Model surgery was performed to predict the surgery outcome. Based on the cephalo-
metric and clinical assessment, the following surgeries were planned: LeFort I osteotomy, bilateral
sagittal split of the mandible, and mandibular anterior segmental osteotomy. The maxilla was
rotated clockwise to upright the excessive upper incisor inclination such that the inclination lies
within the orthodontically treatable perimeter. The lower first premolars were extracted and ante-
rior segmental osteotomy was performed, and the occlusion was set up in a Class III molar rela-
tionship with a large incisor overjet during surgery. This creation of large incisor overjet would
enable decrowding of severely crowded lower anterior teeth and, also, would enable uprighting of
the same. Note the upper second molars are still in crossbite even after surgery planning. A
transpalatal arch will be placed to correct the crossbite post-surgery
9.3 Case Presentation 101
Fig. 9.24 Radiographs taken immediately post-surgery showing achievement of surgical objec-
tives. A constricted with a buccal root torque transpalatal arch was placed across bilateral upper
second molars to correct the crossbite
102 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.25 A chin cap was applied to prevent the mandibular skeletal relapse in the first 3 months
postoperatively. The retroclined lower incisors and excessive overjet were then decompensated and
aligned postoperatively to obtain a normal inclination and overjet
9.3 Case Presentation 103
1-wk post-surgery
1-wk post-surgery
3 months
3 months
4 months 4 months
6 months
Fig. 9.26 Images showing correction of dental malocclusion within a period of 4–6 months. The
most dramatic change was noticed in the lower anterior crowding alleviation and buccal crossbite
correction of upper second molar
104 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
Fig. 9.27 Bilateral cantilever mechanics was used in the lower arch for the uprighting and intru-
sion of lower anterior teeth. 0.017″ × 0.025″ TMA wires were placed in the upper and lower arch
wires
Fig. 9.28 Patient images showing after space closure. TPA was placed in the lower arch for the
correction of uprighting of bilateral second molar
9.4 Conclusion 105
Fig. 9.29 Intra- and extra-oral photographs with lateral cephalograph showing achievement of
treatment objectives
9.4 Conclusion
Skeletal Class III deformities generally require surgery for both the maxilla and
mandible for the correction of skeletal problem. This chapter shows the complexity
of management with emphasis on setting up a ‘transitional occlusion’ such that
postoperatively adjunctive orthodontic treatment can be utilized to transfigure the
orthodontically treatable malocclusion into the solid final occlusion.
Management of Skeletal Asymmetry
with Surgery-First Orthognathic 10
Approach
10.1 Introduction
Although facial symmetry has been rated as a central key for attractiveness [1], it is
a rarity for a human face to be perfectly symmetrical. The correction of maxillo-
mandibular jaw asymmetry primarily depends upon prompt diagnosis of the prob-
lem and a clear differentiation between relative (subclinical) normal asymmetry
from obvious asymmetry arising from a genetic predisposition (congenital),
acquired (injury, disease), and developmental conditions (unknown aetiology) [2].
Facial asymmetry should be determined whether it arises from dental, skeletal,
muscular, functional, or a combination of factors. This is carried out by judicious
application of various diagnostic tools like clinical assessment (measurement), pho-
tographic assessment, and radiographic assessment leading to a collective and
definitive diagnosis of the problem [3]. Once determined that the asymmetry in the
maxillo-mandibular complex (MMC) is due to skeletal and dental aberrations, the
asymmetry should be further categorized into maxilla alone, mandible alone, or a
combination of the both. Several imaging modalities are used to measure and define
the MMC in terms of six degrees of freedom in three-dimensional space including
translation coordinates axes (sagittal, transverse, vertical) and three rotational axes
(pitch, roll, yaw). Chapter 4 provides a comprehensive description of 3D techniques
and modalities that have the capability to assess the MMC. The chapter further elu-
cidates on the assessment of asymmetry both on 2D and 3D imaging system in the
form of identifying various landmarks and planes that can quantify the discrepancy
and also aid in formulating an effective treatment plan. This chapter will focus on
MMC asymmetry pertaining to (1) maxilla and mandible and their interrelationship
in the form of midline discrepancy (midsagittal plane), (2) influence on the menton
or chin position, and (3) maxillary cant and occlusal plane and their subsequent
influence on the MMC in general.
Several authors have proposed various methods to assess the midline discrep-
ancy, of which two methods are of prime importance [4–7]:
The methods are utilized in describing two cases of asymmetry that were man-
aged with surgery-first approach. The two cases present with similar asymmetry, but
on careful observation and evaluation, they are defined by two different types of
asymmetry with varying maxillary occlusal canting. In Case 1, the asymmetry is
defined by uniform maxillary canting (anterior and posterior occlusal canting are in
the same plane and parallel with reference to Frankfort horizontal plane, FHP). In
Case 2, the maxilla is canted in two planes (anterior region does not exhibit any
canting, and posterior region has a cant with reference to FHP). This discernment
leads to different treatment plans albeit almost seemingly similar looking
asymmetry.
10.2 C
ase 1: A Maxillary Occlusal Cant Extending Anteriorly
to Posteriorly: Its Influence on MMC and on Subsequent
Treatment Planning
A 24-year-old male presented with chief complaints: large twisted lower jaw and
difficulty in chewing. Extra-orally, he presented with a concave profile, asymmetri-
cal mandible with a left-sided chin deviation, increased lower anterior facial height,
positive lip step, asymmetrical smile line, and a shallow submental fold (Fig. 10.1).
Intra-orally, he showed Class III molar and canine relationship with the presence of
mild anterior crowding (Fig. 10.1). Cone beam computed tomography scan (CBCT)
showed skeletal asymmetry of the mandible with a chin deviation of 7 mm to the
right side (Fig. 10.1).
The type of asymmetry (skeletal and dental) was ascertained by both clinical and
radiographic (CBCT) evaluations (Fig. 10.2).
Surgical plan: From the clinical presentation and CBCT scan evaluation, it was
apparent that the mandible was skewed to the left side and the Class III deformity
was primarily due to a prognathic mandible and a asymmetric maxilla where the
10.2 Case 1: A Maxillary Occlusal Cant Extending Anteriorly to Posteriorly: Its… 109
Fig. 10.1 Case 1: pre-surgical intra- and extra-oral photographs and CBCT images showing
asymmetry
Fig. 10.2 The asymmetry is predominantly defined in terms of MMC roll rotation. To evaluate
(photographic evaluation) roll relative to soft tissues (top row images), intercommissural line is
used in reference to intercanthal line. On smiling, a positive roll with the left side is raised upward,
and the right side is lowered in relation to the intercommissural line that is evident. Radiographic
evaluation (using CBCT images) (middle and bottom row images) showed, under the influence of
positive roll of the maxilla, the menton has deviated in the left direction. A negative yawing (inter-
gonial plane) (left-side movement) indicating lower anterior yaw relative to the direction of men-
ton deviation. Furthermore, evaluation of the anterior and posterior maxillary cant showed the roll
is similar and parallel to each other in both anterior and posterior regions of the maxillary occlu-
sion. The same form of canting is emulated in the mandibular occlusion also
10.2 Case 1: A Maxillary Occlusal Cant Extending Anteriorly to Posteriorly: Its… 111
Fig. 10.3 Top images showing articulator mounted models exacting the clinical and radiographic
assessments. (Bottom images) A double jaw surgery (LeFort I and bilateral sagittal split osteot-
omy) was planned to correct the maxillo-mandibular complex primarily focussing on the role and
yaw rotation. Once the maxilla’s roll rotation was corrected by impacting maxilla on the right side
(slanted black lines), subsequently, mandible yawing was corrected with asymmetrical bilateral
sagittal setback (more setback on the right side in comparison to left side) such that upper and
lower arch dental midlines were matching in the midsagittal plane (red vertical line). Note the
achievement of Class I molar and canine relation. Furthermore, using CBCT images, a sliding (to
the right side) and advancement genioplasty were planned to further correct the anterior yawing
and recessive chin (shallow submental sulcus)
surgery objectives (Figs. 10.4 and 10.5). One-month post-surgery, 0.016 × 0.022
Sentalloy arch wires were placed for further levelling and anterior vertical elastics
for settling. At 3-month post-surgery, lower intrusion arms were placed, and the
case was finished with second-order bends (Fig. 10.6). The overall treatment time
was 6 months from start to finish. Treatment results: post-treatment images
(Fig. 10.7) and CBCT (Fig. 10.8) showed excellent aesthetic and occlusal results
(Fig. 10.8). Pre- and post-treatment superimposition of CBCT images showed cor-
rection of Class III to Class I skeletal relation with resolution of roll and yaw
rotations.
112 10 Management of Skeletal Asymmetry with Surgery-First Orthognathic Approach
Fig. 10.4 One-week post-surgery extra- and intra-oral images showing fulfilment of surgery
objective
10.3 C
ase 2: Differential Anterior and Posterior Region
Maxillary Occlusal Cant: Its Influence on MMC
and on Subsequent Treatment Planning
Fig. 10.5 One-week post-surgery CBCT images (top row images) showed resolution of the prob-
lem. One-week post-surgery CBCT images were superimposed on pre-surgery images (bottom
row images). Corrections could be appreciated in MMC rotation and mandibular yaw rotation with
chin centred (midsagittal plane)
largely due to the yaw rotation of the mandible itself, unlike Case 1, where the
asymmetry is defined by the combination of maxilla-mandibular complex’s roll and
yaw rotation. This aforementioned discernment plays an important key during sur-
gery planning.
Surgical plan: Bimaxillary surgery with surgery-first approach was planned.
LeFort I impaction to correct the MMC role rotation and mandibular asymmetrical
setback to correct the yaw rotation of mandible. Further, if required, (1) advance-
ment genioplasty would be performed based on the amount of setback achieved
during the surgery, and (2) bilateral upper and lower first premolars will be extracted
for the correction of teeth proclination and crowding (Fig. 10.10).
The dentition was bonded with 0.022″ preadjusted brackets. 0.014″ Sentalloy
wire was placed in the upper and lower arches (Fig. 10.11). One-week post-surgical
extra-oral images and CBCT images showed fulfilment of surgery objectives
(Fig. 10.12). At 1 month, there was further improvement in the occlusion on the left
side (Fig. 10.13). A transpalatal arch was placed in the upper arch across bilateral
second molars to correct the crossbite (Fig. 10.14). The overall treatment time was
8 months. Treatment results: post-treatment images and CBCT showed excellent
aesthetic and occlusal results. Pre- and post-treatment superimposition of CBCT
images showed correction of Class III to a Class I skeletal relationship with resolu-
tion of roll and yaw rotations (Figs. 10.15 and 10.16).
114 10 Management of Skeletal Asymmetry with Surgery-First Orthognathic Approach
Fig. 10.6 Intra-oral images showing in between treatment at 1 month (top images), 2 months
(middle images), and 3 months (bottom images) post-surgery
10.3 Case 2: Differential Anterior and Posterior Region Maxillary Occlusal Cant: Its… 115
Fig. 10.8 (Top row images) Superimposition of 1-week post-surgery (green colour) CBCT
images on post-surgery images (red colour) showed most of the surgery objectives were main-
tained and also results were stable; however, extrusion of upper dentition was also noted which
made the mandible slightly moved to the left. (Bottom row images) Superimposition of pre-
treatment (grey colour) and post-treatment (red colour) images showed great improvement of man-
dibular asymmetry, maxillary occlusal cant, and decrease of vertical facial height
10.3 Case 2: Differential Anterior and Posterior Region Maxillary Occlusal Cant: Its… 117
Fig. 10.9 Pre-treatment intra- and extra-oral photos with CBCT images
118 10 Management of Skeletal Asymmetry with Surgery-First Orthognathic Approach
Fig. 10.10 The asymmetry is partly defined in terms of maxilla roll rotation and mandible yaw-
ing. The surgery was planned to correct both roll and yaw with achievement of a treatable maloc-
clusion. The roll rotation of maxilla was corrected by LeFort I minimal impaction, and yawing was
corrected by asymmetrical mandibular setback. Note, due to the varied posterior occlusal canting,
left-side posterior teeth do not have an occlusion with antagonist teeth, especially, at the second
molar region. A transpalatal arch will be used to correct the second molar crossbite
Fig. 10.11 Pre-surgery bonding and banding were done with no bracket on the bilateral upper and
lower first premolars. The brackets were not bonded on the aforementioned teeth so that, if
required, those teeth will be extracted post-surgery, after evaluation of teeth inclination from post-
surgery CBCT
10.3 Case 2: Differential Anterior and Posterior Region Maxillary Occlusal Cant: Its… 119
Fig. 10.12 One-week post-surgery showing improvement of mandibular asymmetry. Note sliding
advancement genioplasty was performed to correct the yawing and recessive chin
120 10 Management of Skeletal Asymmetry with Surgery-First Orthognathic Approach
Fig. 10.14 Intra-oral images showing in between treatment at 2 months (top images), 3 months
(middle images), and 4 months (bottom images) post-surgery. A constricted transpalatal arch with
buccal root torque was placed across bilateral upper second molar to correct the crossbite
122 10 Management of Skeletal Asymmetry with Surgery-First Orthognathic Approach
Fig. 10.16 (Top row images) Superimposition of 1-week post-surgery (green colour) CBCT
images on post-surgery images (red colour) showed fulfilment of the surgery objectives. (Bottom
row images) Superimposition of pre-treatment (grey colour) and post-treatment (red colour)
images showed stable results
References 123
10.4 Conclusion
References
1. Brookes M, Pomiankowski A. Symmetry is in the eye of the beholder. Trends Ecol Evol.
1994;9(6):201–2.
2. Thiesen G, Gribel BF, Freitas MPM. Facial asymmetry: a current review. Dental Press J Orthod.
2015;20(6):110–25.
3. Cevidanes LH, Alhadidi A, Paniagua B, Styner M, Ludlow J, Mol A, et al. Three-dimensional
quantification of mandibular asymmetry through cone-beam computerized tomography. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(6):757–70.
4. De Momi E, Chapuis J, Pappas I, Ferrigno G, Hallermann W, Schramm A, et al. Automatic
extraction of the mid-facial plane for cranio-maxillofacial surgery planning. Int J Oral
Maxillofac Surg. 2006;35(7):636–42.
5. Cevidanes LH, Heymann G, Cornelis MA, DeClerck HJ, Tulloch JC. Superimposition of
3-dimensional cone-beam computed tomography models of growing patients. Am J Orthod
Dentofac Orthop. 2009;136(1):94–9.
6. Xia JJ, Gateno J, Teichgraeber JF, Christensen AM, Lasky RE, Lemoine JJ, et al. Accuracy of
the computer-aided surgical simulation (CASS) system in the treatment of patients with com-
plex craniomaxillofacial deformity: a pilot study. J Oral Maxillofac Surg. 2007;65(2):248–54.
7. Cevidanes LH, Styner MA, Proffit WR. Image analysis and superimposition of 3-dimensional
cone-beam computed tomography models. Am J Orthod Dentofac Orthop. 2006;129(5):611–8.
Pre- and Post-surgery Patient Care
Checklist and Patient Instruction 11
11.1 Introduction
11.2 P
re- and Post-surgery Checklist: Category, Conditions,
Assessment Tools, and Management Plan
Table 11.1 discusses some of the pre- and post-surgery conditions, such as sys-
temic factors, patient’s informed consent, medication/anaesthesia clearance, pre-
operative anxiety assessment, social support, orthodontic, and surgery
assessment.
Systemic evaluation is perhaps the most important element that determines the asso-
ciated overall surgical risk and outcome of the surgery. Conditions like heart dis-
eases, respiratory disease, and liver and renal functions should be assessed and
considered in relation to risk when performing any surgery, along with a thorough
assessment of allergies and undesirable medication side effect [1]. Routine preop-
erative tests are used to assess several aspects like pre-existing conditions, identify
appropriate referrals, predict postoperative complications, and formulate a compre-
hensive management plan [2]. Current recommended guidelines should be fol-
lowed, i.e. American College of Cardiology/American Heart Association (ACC/
AHA) recommends comprehensive guideline on perioperative cardiovascular eval-
uation [3]. Before using preoperative tests, it is practical to ascertain proper ‘his-
tory’ and comprehensive ‘physical examination’, and once these two are conducted
correctly, studies suggest that as much as 70% of preoperative testings are unneces-
sary [4–6].
The patient’s objective of opting for jaw surgery should be considered with a
psychological perspective with regard to patient’s fears, apprehensions of sur-
gery which has to be appropriately addressed in order to achieve a successful
execution of the treatment plan [7]. Patients should be educated about the tran-
sitional malocclusion following post-surgery in SFOA and difficulty associated
with chewing with a possible aggravation of postoperative anxiety [7, 8]. Prior
to surgery, psychological preparation in the form of addressing previous unpleas-
ant dental experience, postoperative major changes in facial aesthetics, and the
challenges associated with adjusting to the new face not only motivate the
patient but also allow the patient to manage any anxiety issues and enhance the
patient-doctor rapport. Anxiety assessment tests should be judiciously used to
determine the associated anxiety, stress levels, knowledge, attitude and behav-
iour towards jaw surgery, and degree of exposure of previous traumatic events
(Table 11.1). If the need arises, the patient should be referred for professional
counselling in order to successfully manage the anxiety associated with the jaw
surgery.
11.2 Pre- and Post-surgery Checklist: Category, Conditions, Assessment Tools… 129
Several studies have shown that strong social support in the form of emotional and
informational support significantly increases positive outcomes as opposed to
patients that have lower levels of social support resulting in worse outcomes.
Enhanced social associations have had a significantly lower levels of post-surgery
pain levels, decreased administration of opioid (narcotic) pain medications, and a
faster recovery rate after surgery [14, 15]. Appropriate surveys or questionnaires
should be administered prior to surgery to assess the extent of preparedness of a
patient in terms of social well-being and adequacy of social support. Provisions
should be made to identify and address the psychosocial barriers that preclude the
full participation of the patient. The multidisciplinary team should disseminate
useful information pertaining to surgery and various postoperative coping skills
such so that the patient can coherently participate in the process. Support groups,
website links with comprehensive information, a hospital-based support system
(phone contact number, mail address), and a qualified social worker information
are some of the essential and supplemental support systems that should be pro-
vided to the patient and care givers for effective, impactful, and meaningful sup-
port. The aforementioned guidance enhances the autonomy of the patient which in
130 11 Pre- and Post-surgery Patient Care Checklist and Patient Instruction
turn positively influences the recovery as the knowledge allows the patient to be
better equipped [16].
Patient’s informed consent forms should contain all components of informed con-
sent with full disclosure of the nature of procedure and a comprehensive plan such
that the patient can make an informed decision to proceed with the surgery. Every
informed consent should encompass three basic tenets of ethical practice, namely,
(1) preconditions, (2) information, and (3) consent, and essentially should be based
on best practices. The healthcare provider must disclose information including the
benefits and risks associated with the procedure and the possible alternatives in lay-
man’s terms a non-jargon-based language [19, 20].
Early and effective postoperative pain management increases the possibility of early
mobilization, enhances patient comfort, and decreases risk of morbidity with
reduced incidence of prolonged neuropathic pain which results in a timely or even
an early discharge. In jaw surgery patients, postoperative pain can emanate from
three distinct areas, namely, (1) face (lips, cheeks, and muscles); (2) ear, nose, and
throat; and (3) teeth and TMJ (Table 11.1). The pathophysiology, severity, and con-
sequences of pain should be assessed as early as possible by using both subjective
and objective assessment methods. Most effective pain control therapeutic
11.3 Instructions for Patients and Care Givers: Dos and Don’ts 131
modalities should be discussed and administered after evaluating the nature of the
pain, type of medication, most feasible route of administration, adverse effects,
potential benefits, and therapy duration [21, 22].
Poor oral hygiene poses as a risk factor for postoperative wound infection [23].
Bacteraemia detected in patients that underwent jaw reconstruction surgery showed
a predominance of streptococci viridans isolated from the infection. Such bacter-
aemia induced infective endocarditis in patients with congenital or acquired car-
diac anomalies which could lead to a potential life-threatening situation [24].
Studies have shown that good oral care reduced the microorganism’s number
which in turn led to decreased incidence of bacteraemia [25]. Prior to surgery,
individuals undergoing jaw surgery must be given proper oral hygiene instructions,
importance of oral toilet and the maintenance of oral hygiene post-surgery. All
efforts should be made to evaluate oral hygiene with identification of source of
infections, if any, and appropriate measures should be taken to counter them
(Table 11.1).
The dos and don’ts encompass a plethora of settings for pre- and postoperative con-
siderations, such as general well-being and diet, oral hygiene, physical activity or
ambulatory care, psychosocial response, and pain management/wound recovery/
swelling for effective management of the patient. The authors have enumerated dos
and don’ts for patients and care givers’ ease of understanding (Fig. 11.1).
132 11 Pre- and Post-surgery Patient Care Checklist and Patient Instruction
Instructions • Follow all the instructions • Carefully consider and evaluate hospital discharge,
provided by your orthodontist home care, and post-surgery rehabilitation plan.
and surgeon • Call the clinic for a follow-up visit
• Eat or drink previous night • Wear the elastics as directed, if in doubt, inform
• Report of any breakage of • Not following instructions
brackets or wires and get • Jewelry, make-up or any other the clinic ;
items that hinder surgery • Staying alone
it fixed ✓ Use mirror to wear elastics
• Having negative thought, not communicating
• Tight fitting clothing' ✓ Use hooks to place the elastics
• Follow the instructions
provided by the anesthetic ✓ Consider additional help
team • If the bite wafer is in place, follow the instructions
on how to manage the wafer
11.4 Conclusion
Comprehensive pre- and post-surgery patient care checklist and patient instruction
provide a prelude to high-quality predictable outcome. Patient care begins as soon
as the patient seeks first consultation for jaw surgery and continues until the end of
treatment. The orthodontist and surgeon must thoroughly evaluate every patient in
order to optimize the clinical outcome.
References 133
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Potential Complications
and Management of SFOA 12
12.1 Introduction
Frequent complications that can occur during surgery are (1) bracket debonding, (2)
ligature wire breakage, (3) ill-fitting of surgical splints, and (4) inadvertent move-
ment of teeth. Rebonding a bracket during surgery is impractical as it unnecessarily
disrupts the surgery, and also the difficulty will be ensuring an uncontaminated dry
field for bonding. Efforts must still be made to attempt to rebond the brackets as
soon as possible. Post-surgery bonding is difficult, as well, as the patient has limited
mouth opening and the patient is usually in quite a bit of discomfort at that point.
One must take cognizance of the fact that a tooth or teeth without brackets will not
move and will not be able to utilize the RAP effect post-surgery. Usage of moisture
insensitive primer (MIP; Transbond; 3M Unitek, Monrovia, CA) could be used for
bonding post-surgery to mitigate bonding issues.
Ill-fitting or breakage of surgical splint is a possibility due to the use of poor-
quality resin, and surgical splints become extremely thin due to over-trimming,
which can affect the outcome even in the hands of the most skilled surgeon. Poor fit
138 12 Potential Complications and Management of SFOA
Table 12.1 (continued)
Stage Complication Causes Resolution
Post-surgery 1. Occlusion 1. Teeth are in 1. (a) Judicious use of
instability transitional occlusion settling elastics as
2. Limited mouth 2. Settling elastics and enumerated in Chap. 5
opening bite wafer restrains (b) Use of chin cup for
3. Decreased chewing the mouth opening Class III patients
efficiency 3. Teeth are not in (c) Early removal of
4. Excessive dryness final occlusion splint (within a week
of lips 4. Lack of liquid diet post-surgery)
5. Open bite 5. (a) Condyle (d) Use of TAD’s and
(a) Immediate displacement during cantilever mechanics for
(b) Late fixation. Inadequate rapid correction of teeth
6. Dental damage removal of bony utilizing RAP
(a) Teeth broken or interferences 2. Intermittent use of
chipped off (b) Collapse of elastics is encouraged
(b) Pulp necrosis, transverse expansion. 3. Soft diet is preferred
root resorption Failure to maintain the 4. Liquid diet is
(c) Decalcification lateral expansion encouraged, and copious
7. Periodontal correction use of petroleum jelly is
complications. 7. (a) Mishandling of advised
(a) Dehiscence instruments 5. (a) Ensure proper fit of
(b) Gingival (b) Close proximity the splint
recession or of interdental cut (b) Minimize mobility
fenestration (c) Poor oral (c)Additional titanium
hygiene plate fixation across
7. (a) Access incision segments
too close to teeth 6. (a) Proper use of
(b) Osteotomy cut instruments
too close or involving (b) Maintain a minimum
attached gingiva of 2–3 mm interdental
distance from the adjacent
periodontal ligament space
(c) Early oral toileting is
encouraged with
professionally effective oral
healthcare
7. (a) Avoid too close
access incision
(b) Placement of
osteotomy cut in movable
gingiva
(c) A good access design
with wide gingival cuff of
more than 1 cm must be
contemplated
140 12 Potential Complications and Management of SFOA
of the surgical splint could be due to the movement of the teeth or warpage of the
resin, caution should be exercised to avoid any inadvertent tooth movement, and the
surgical splint can be prevented warpage by dipping in sterile non-reactive liquid
(e.g. water, betadine solution) to provide enough moisture.
Although surgery-related complications are not in the scope of the book, some of
the commonly encountered problems are mentioned in Table 12.2 and solutions also
mentioned.
Table 12.2 (continued)
Stage Complication Causes Resolution
Post- 1. Infection 1. Poor oral hygiene, 1. Meticulous hygiene
surgery 2. Neurosensory pre-existing conditions maintenance, rule out any
disturbance 2. Smoking or iatrogenic pre-existing oral debilitations and
3. Vascular surgical factors resulting treat appropriately, antibiotics
compromise/aseptic in compromised vascular therapy
necrosis flow 2. Promotion of nerve regrowth
4. Postoperative 3. Inadvertent medication (e.g. resveratrol)
gingival recession manipulation of soft 3. Surgical debridement of
5. Extensive facial tissues necrotic areas, hyperbaric oxygen
swelling 4. (a) Condyle therapy
6. Delayed bony displacement during 4. Appropriate dressing/packing
segments union fixation of the wound
7. Unfavourable Inadequate removal of 5. Minimize operation time,
segmentalization/ bony interferences minimize tissue manipulation
fracture (b) Collapse of 6. Ensure complete bony cuts to
8. TMJ resorption transverse expansion. avoid unpredictable propagation
9. Prolonged intense Failure to maintain the of osteotomy cuts
pain lateral expansion 7. Re-intervention for proper
10. Reduced nutrition correction segmentation fixation
5. Non-judicious use of 8. For severe cases, condyle
surgical instruments amputation and prosthetic
6. Extensive tissue substitution
manipulation 9. Dissatisfied patients show
7. Incomplete interdental worse pain symptoms, evaluate
bony cuts/unfavourable ‘body dysmorphic disorder’
fracture 10. Adequate nutrition and
8. Inadequate nutrition caloric intake are vital
Fixation of the maxillary
segments, the lack of
consolidation over an
extended period may
cause pseudoarthrosis
9. Increase in force
caused by the autorotation
of the mandible
10. Dissatisfied patient
could be a possibility
142
High
Medium
Risks identification Low
Risk response
• implementation of preventative • Emphasize multidisciplinary team • Application of Immediate or • involvement of specialty services
measures approach (eg Exhaustive t delayed proactive risk (e.g managing body dysmorphic
• Integration of primary, secondary, treatment plan exploring all intervention techniques and tools disorder)
and tertiary prevention methods possibilities of risk) • ( eg reintervention jaw surgery, • Execution of specific actions
(e.g. enforcement of oral hygiene • Enhancing risk monitoring behavior countering relapse tendency ) • Prioritizing risk and addressing
habits, providing psychological Implementing a comprehensive • enactment of a risk contingency the most pressing issue through
motivation to the patient) •
feed-back loop plan collaboration
• Anticipating risk and equipping to
• Persistent quality improvement
tackle
• Develop further risk mitigation plans
12 Potential Complications and Management of SFOA
12.4 Conclusion
The risk management process (Fig. 12.1) should be clearly understood by both the
orthodontist and surgeon, and emphasis should be placed on the risk identification
and assessment such that a suitable response could be formulated and executed for
the prevention, mitigation, acceptance, and risk transference.
References
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jaw orthognathic surgery using a computer-aided surgical simulation (CASS) protocol. Part 2:
three-dimensional cephalometry. Int J Oral Maxillofac Surg. 2015;44:1441–50.
2. Gateno J, Alfi D, Xia JJ, Teichgraeber JF. A geometric classification of jaw deformities. J Oral
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feasibility of computer-aided surgical simulation (CASS) in the treatment of complex cranio-
maxillofacial deformities. J Oral Maxillofac Surg. 2007;65:728–34.
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the computer-aided surgical simulation (CASS) system in the treatment of patients with com-
plex craniomaxillofacial deformity: a pilot study. J Oral Maxillofac Surg. 2007;65:248–54.
5. Rustemeyer J, Eke Z, Bremerich A. Perception of improvement after orthognathic surgery: the
important variables affecting patient satisfaction. Oral Maxillofac Surg. 2010;14:155–62.
6. Vulink N, Rosenberg A, Plooij J, Koole R, Bergé S, Denys D. Body dysmorphic disorder
screening in maxillofacial outpatients presenting for orthognathic surgery. Int J Oral Maxillofac
Surg. 2008;37:985–91.
7. Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Miura S. Demographic features of
patients seeking cosmetic surgery. Psychiatry Clin Neurosci. 1998;52:283–7.
8. Walker F, Ayoub AF, Moos KF, Barbenel J. Face bow and articulator for planning orthognathic
surgery: 2 articulator. Br J Oral Maxillofac Surg. 2008;46:573–8.
9. Walker F, Ayoub AF, Moos KF, Barbenel J. Face bow and articulator for planning orthognathic
surgery: 1 face bow. Br J Oral Maxillofac Surg. 2008;46:567–72.
10. Ellis E, Tharanon W, Gambrell K. Accuracy of face-bow transfer: effect on surgical prediction
and postsurgical result. J Oral Maxillofac Surg. 1992;50:562–7.
11. Gateno J, Xia JJ, Teichgraeber JF, editors. New methods to evaluate craniofacial deformity and
to plan surgical correction. Seminars in orthodontics. Amsterdam: Elsevier; 2011.
12. Plooij JM, Maal TJ, Haers P, Borstlap WA, Kuijpers-Jagtman AM, Bergé SJ. Digital three-
dimensional image fusion processes for planning and evaluating orthodontics and orthognathic
surgery. A systematic review. Int J Oral Maxillofac Surg. 2011;40:341–52.
Outcome Assessment of Surgery-First
Orthognathic Approach 13
13.1 Introduction
Various outcomes need to be assessed and proved feasible and efficient before a
certain treatment modality is deemed as a viable modality to replace the conven-
tional mode of treatment. In a treatment approach such as SFOA that involves at
least two disciplines, one needs to ascertain certain outcomes such as clinical, psy-
chological, and health resource utilization and compare this with the current modal-
ity of treatment for the evaluation of the true extent of feasibility and reliability
(Fig. 13.1).
13.2 T
reatment Duration of SFOA Versus Conventional
Orthognathic
On an average, the total treatment duration for the conventional jaw surgery
approach is 18–36 months, of which a major portion of time (about 17 months) is in
the pre-surgical orthodontic phase [1, 2] (Table 13.1). Shortening the pre-surgical
orthodontic treatment phase is the main emphasis of surgery-first orthognathic
approach. The impact of SFOA on the pre-surgical orthodontics phase and its influ-
ence on the overall treatment will be discussed. In conventional jaw surgery, pre-
surgical orthodontic phase is employed for some of the following reasons: (1) dental
decompensation, (2) arch alignment, (3) maxilla-mandibular arch coordination, and
(4) correction of curve of Spee, thus making the pre-surgical phase significantly
longer. In SFOA, the pre-surgical phase of active orthodontic treatment is not
Assessment
Morbidity/General
Health Hospitalization/ ward
QoL
OHQoL
Skeletal Dental Soft-tissue Manpower : planning,
execution, lab procedures
Patient
Muscles of satisfaction/Bodyimage
mastication Equipment:
Osteotomy stability TMJ stability Teeth inclination Patient Softwares, navigation
Occlusal stability
/relapse /relapse and angulation perception/motivation equipment, 3D printers
Mouth opening
Transverse Neurovascular
Vertical
Sagittal
Single or double
jaw surgery
Immediate/Short-term Long-term
outcome Assessment outcome assessment
13 Outcome Assessment of Surgery-First Orthognathic Approach
Fig. 13.1 Figure depicting the various scenarios of SFOA outcome assessment
Table 13.1 Table describing some of the studies on SFOA’s stability, oral health-related quality of life (OHRQoL), and psychosocial well-being
Method of
Outcome primary/ measurement/outcome
Author/year Study design Participant Intervention Comparison secondary domain Conclusion
Park/2016 Case-control 40 pts.: 20 SFOA Conventional Postoperative Cephalometric No significant
[3] retrospective conventional jaw bimaxillary surgery, stability/relapse radiographs/skeletal differences
surgery surgery bimaxillary rate and dental between the two
(25.25 ± 3.77 years) surgery groups in terms of
and 20 SFOA the postoperative
(22.60 ± 5.39 years) stability
Huang/2016 Case-control 50 pts.: conventional SFOA Class III Conventional Oral health-related Two questionnaires: SFOA showed no
[4] prospective jaw surgery malocclusion surgery, quality of life and the Dental Impact on deterioration stage
(24.2 ± 5.8 years) and bimaxillary satisfaction Daily Living and of quality of life
SFOA surgery between surgery- 14-item Oral Health score which leads
(25.2 ± 4.2 years) first and Impact profile to better
orthodontics-first satisfaction
orthognathic compared to
surgery patients orthodontics-first
group
Choi/2015 Case-control 56 pts. (avg. age, Surgery-first Conventional Reliability of a Surgery-first approach, SFOA is
[5] prospective 22.4 years): approaches for surgery surgery-first dental model. predictable and
conventional jaw patients with orthognathic Cephalometric applicable to treat
surgery (n, 24) and skeletal Class approach without assessment (skeletal Class III
SFOA (n, 32) III dentofacial pre-surgical and dental) dentofacial
13.2 Treatment Duration of SFOA Versus Conventional Orthognathic
Method of
Outcome primary/ measurement/outcome
Author/year Study design Participant Intervention Comparison secondary domain Conclusion
Wang/2018 Retrospective 55 pts.: conventional Bilateral Conventional Compare the Three-dimensional Regardless of the
[6] cohort study jaw surgery (n, 29; sagittal split surgery postoperative (3D) CT images timing of the
22.2 ± 3.8 years) and ramus changes of the operation (OFA vs
SFOA (n, 26; osteotomy for condylar position SFA), the
21.6 ± 3.3 years) mandibular after mandibular perioperative and
prognathism setback surgery postoperative
using OFA using the changes of the
orthodontics-first condylar position
approach (OFA) after mandibular
and surgery-first setback surgery are
approach (SFA) equivalent
Ko/2011 [7] Case-control 53 pts.: modified SFOA Modified Post-surgical Lateral cephalograph No difference in
retrospective conventional jaw conventional dental and skeletal cephalometric SFOA and
surgery (n, 35; surgery (MC) stability and measurements conventional
22.0 ± 4.1 years) and treatment efficacy surgery in amount
SFOA (n, 18; of skeletal Class of skeletal
24.6 ± 4.9 years) III malocclusion correction and
between 2 post-surgical
pre-surgical relapse, as well as
orthodontic treatment duration
managements
Guo/2018 Retrospective Symmetry group (n, SFOA SFOA Corrective Three-dimensional Corrected
[8] cohort study 17; 22.9 ± 4.4 years) mandibular mandibular outcomes and analysis. 3D facial CT outcomes showed
and asymmetry group prognathism prognathism transverse stability good postoperative
(n, 12; with asymmetry without facial after surgery-first stability in both the
20.5 ± 2.2 years) asymmetry surgical- symmetry and
orthodontic asymmetry groups
treatment in
13 Outcome Assessment of Surgery-First Orthognathic Approach
mandibular
prognathism
Method of
Outcome primary/ measurement/outcome
Author/year Study design Participant Intervention Comparison secondary domain Conclusion
Joh/2013 [9] Retrospective 32 adult pts.: Minimal MPO in Class CPO In Class Changes in the No significant
Lateral cephalograph
cohort study pre-surgical III III hard and soft cephalometric differences
orthodontics (MPO) (n, malocclusion malocclusion tissues and the measurements between the MPO
16) and conventional treatment efficacy and CPO groups in
pre-surgical of two-jaw surgery the hard and soft
orthodontics (CPO) (n, tissue
16) cephalometric
variables. MPO
group had a shorter
treatment time
Jeong/2018 Retrospective Conventional jaw SFOA in Conventional Long-term Lateral cephalograph SFOA can achieve
[10] study surgery (n, 51; skeletal Class surgery outcomes of cephalometric similar long-term
23.1 years) and SFOA III dentofacial vertical skeletal measurements vertical stability
(n, 104; 23.3 years) deformities stability results to the
conventional
surgery
Liao/2018 Retrospective N, 41, females. SFOA in Determine whether Photographs and study SFOA improves
[11] cohort study 24.0 ± 4.9 years skeletal Class the SFOA and the models facial asymmetry
III facial guidelines for using the described
asymmetry setups of the guidelines
13.2 Treatment Duration of SFOA Versus Conventional Orthognathic
models could be
used to improve
facial symmetry
with bimaxillary
surgery
(continued)
149
Table 13.1 (continued)
150
Method of
Outcome primary/ measurement/outcome
Author/year Study design Participant Intervention Comparison secondary domain Conclusion
Choi/2015 Retrospective N, 35 pts.; 24.7 years SFOA Posterior Lateral cephalograph SFOA MMC did
[12] study clockwise pharyngeal airway cephalometric not cause severe
maxillo- change measurements posterior airway
mandibular space changes
complex
(MMC) skeletal
Class III
deformities
Zhou/2016 Retrospective 40 pts., conventional SFOA in Conventional Compare treatment Lateral cephalograph SFOA and
[13] cohort study jaw surgery (n, 20; skeletal Class surgery efficacy and cephalometric conventional
23.1 years) and SFOA III dentofacial post-surgical measurements surgery showed
(n, 20; deformities stability similar extents and
20.9 ± 2.1 years) directions of
skeletal changes in
patients with Class
III malocclusion
Feu/2017 Prospective 16 pts., conventional SFOA in Conventional Oral health-related Orthognathic Quality OHRQoL
[14] study jaw surgery (n, 8; skeletal Class surgery quality of life of Life Questionnaire improved
26.8 ± 7.1 years) and III dentofacial (OHRQoL), (OQLQ) and the Oral significantly in
SFOA (n, 8; deformities quality of the Health Impact SFOA
22.9 ± 5.4 years) orthodontic Profile-short version
outcome, and (OHIP-14)
average treatment
duration
Park/2015 Retrospective 26 pts., conventional SFOA in Conventional Compare the Orthognathic QoL SFA might have an
[15] study jaw surgery (n, 15; skeletal Class surgery quality of life Questionnaire advantage over
25.0 ± 3.2 years) and III dentofacial (QoL) (OQLQ) CTM group in
SFOA (n, 11; deformities terms of no
13 Outcome Assessment of Surgery-First Orthognathic Approach
(continued)
Table 13.1 (continued)
152
Method of
Outcome primary/ measurement/outcome
Author/year Study design Participant Intervention Comparison secondary domain Conclusion
Wang/2017 Longitudinal 50 pts., conventional SFOA in Conventional Oral health-related Oral health-related Both treatment
[18] prospective jaw surgery (n, 25; skeletal Class surgery quality of life quality of life methods can obtain
cohort study 25.1 ± 6.8 years) and III dentofacial (OHRQoL) the same results
SFOA (n, 25; deformities questionnaire
25.4 ± 6.4 years)
Ko/2013 Retrospective 45 pts., conventional SFOA in Groups based Identify the Lateral cephalograph Factors for SFOA
[19] cohort study jaw surgery (n, 25; skeletal Class on the amount parameters related cephalometric instability are
25.1 ± 6.8 years) and III dentofacial of horizontal to skeletal stability measurements larger overbite, a
SFOA (n, 25; deformities relapse after SFOA deeper curve of
25.4 ± 6.4 years) Spee, a greater
negative overjet,
and a greater
mandibular setback
Kim/2014 Retrospective 61 pts., conventional SFOA in Conventional Stability of Lateral cephalograph Mandibular sagittal
[20] cohort study jaw surgery (n, 38; skeletal Class surgery mandibular cephalometric split ramus
21.6 ± 3.5 years) and III dentofacial setback surgery measurements osteotomy in
SFOA (n, 23; deformities SFOA is less stable
23.0 ± 6.3 years) than conventional
surgery
Choi/2016 Retrospective 37 pts., conventional SFOA in Conventional Postoperative Lateral cephalograph IVRO in SFOA
[21] cohort study jaw surgery (n, 17; skeletal Class surgery using skeletal and dental cephalometric shows linear
20.8 ± 0.9 years) and III dentofacial IVRO changes measurements correlation with
SFOA (n, 20; deformities mandibular setback
21.1 ± 0.7 years) using intra-oral and vertical
vertical ramus movement of
osteotomy mandible
(IVRO)
13 Outcome Assessment of Surgery-First Orthognathic Approach
Method of
Outcome primary/ measurement/outcome
Author/year Study design Participant Intervention Comparison secondary domain Conclusion
Baek/2010 Retrospective 11 pts.; SFOA in Pre-treatment Evaluate the Lateral cephalograph The mandible
[22] cohort study 22.9 ± 2.5 years skeletal Class baseline surgical movement cephalometric seems to relapse
III dentofacial and postoperative measurements forward
deformities orthodontic immediately after
treatment wafer removal and
before labioversion
of the lower
incisors
Liao/2010 Retrospective 33 pts., conventional SFOA in Conventional Evaluate treatment Lateral cephalograph, Patients receiving
[23] study jaw surgery (n, 13; skeletal Class surgery in outcome in terms Peer Assessment pre-surgical
21.0 ± 4.0 years) and III open bite skeletal Class of facial aesthetics, Rating orthodontics
SFOA (n, 20; III open bite occlusion, stability, undergo longer
23.0 ± 4.0 years) and efficiency treatment time than
those receiving no
pre-surgical
orthodontic
13.2 Treatment Duration of SFOA Versus Conventional Orthognathic
153
154 13 Outcome Assessment of Surgery-First Orthognathic Approach
performed, minimizing the time required. The ‘model surgery’ is employed to pre-
view the post-surgery occlusion in SFOA. Two scenarios are worth mentioning
whilst estimating the amount of time that will be taken by orthodontic treatment
post-surgery when previewing the transitional occlusion on a model surgery.
If the model surgery is able to show that the tooth movement that shall be com-
menced post-surgery is well within the realms of conventional orthodontic tooth
movement, then the overall treatment time could be significantly reduced. The
reduction in time comes in part from utilizing the RAP effect post-surgically. Smart
planning of the surgery could also rely on surgical movements to assist in some
orthodontic correction.
If the model surgery shows some of the below-mentioned scenarios (and not limited
to), then the SFOA approach may not significantly reduce the overall treatment time
as the following scenarios may take beyond the 4–5 months of RAP period to com-
plete the post-orthodontics movement.
But the question is, can the pre-surgical phase be eliminated in all the SFOA
cases, thereby reducing the total treatment time? Woo et al. conducted a study to
investigate actual time taken by SFOA Class III cases and compared with conven-
tional jaw surgery cases and reported that the SFOA for jaw surgery can accelerate
orthodontic treatment and reduce the total duration of treatment needed to correct
dentofacial deformities when tooth extraction is not needed, and the total treatment
time may be associated with many factors including host factors (extent of severity
in three dimensions) and surgical factors (surgeons skill, fixation methods, and mus-
cle response). They further inferred that, regardless of surgery approach, once the
teeth extraction is planned, the tooth mobilization may occur for some time (consid-
ering the RAP period); nonetheless, once the RAP period subsides, the tooth move-
ment would follow its own regular course. Liao et al. conducted a study to evaluate
the effect of pre-surgical and no pre-surgical orthodontics on the treatment outcome
in terms of facial aesthetics, occlusion, stability, and efficiency in skeletal Class III
open bite cases. One key finding of this study was a significant overall reduction in
13.4 Quality of Life Outcomes and Psychological Status for SFOA 155
In the Liao et al. study, they showed good stability in horizontal directions (at pogonion)
with mild rate of relapse in both SFOA and conventional jaw surgery groups. However,
vertical mandibular stability worsened in the non-pre-surgical orthodontics group, but
the direction of instability was favourable for open bite correction in the skeletal Class
III patients that were studied [23]. Ko et al. reported minimal differences in stability
between conventional jaw surgery and SFOA; after conducting further research on the
correlation between surgery-first orthognathic approach and relapse factors, they also
reported that setback, overbite, overjet, and curve of Spee were closely related to the
relapse rate and concluded that the initial overbite may be an indicator in predicting pos-
sible skeletal relapse of mandibular setback surgery in SFOA [19].
Wang et al. conducted a retrospective cohort study to evaluate the positional
changes of the condyle after mandibular setback surgery in SFOA and conventional
jaw surgery approach. Their computed tomography study measured the bodily shift
of the condylar centre, and rotational movement of the condylar head of preopera-
tive, postoperative, and at 6-month follow-up images concluded that there was no
significant difference regardless of the timing of the operation to the changes of the
condylar position after mandibular setback surgery [6]. Guo et al. conducted a study
to evaluate the corrective outcome and transverse stability in Class III facial asym-
metry and observed good stability postoperatively in both the symmetry and asym-
metry groups [8].
Most of the outcome assessment studies are conducted on skeletal Class III indi-
viduals and have been reported that the relapse associated with SFOA is similar to
conventional jaw surgery [3, 8, 24, 25, 26]. However, there is little evidence on the
benefits, if any, for skeletal Class II malocclusion. Further research can be done on
this area.
Several studies have dealt with the quality of life (QoL) of conventional jaw surgery
that typically involves a pre-surgical orthodontic phase and concluded that, although,
the overall patient experience in terms of treatment outcome, social relationship,
156 13 Outcome Assessment of Surgery-First Orthognathic Approach
facial aesthetics, and oral function had improved post-treatment; the long course of
treatment, worsening of the facial profile especially during pre-surgical orthodon-
tics phase, and functional unease such as masticatory discomfort affected the QoL
negatively [27–33]. Studies have shown that oral health-related quality of life
(OHRQoL) is worse in pre-surgical orthodontics phase than in the post-surgical
orthodontic phase [32, 33].
These aforementioned reasons as a result of conventional jaw surgery, especially
the pre-surgical orthodontics phase, is one of the main reasons for SFOA’s emer-
gence. Several tests and questionnaires have been implemented to assess the
patients’ psychological status and quality of life outcomes. Some of the commonly
used ones are (1) Orthognathic QoL Questionnaire (OQLQ), (2) oral health-related
quality of life (OHRQoL), (3) Resilience Scale for Adults (RSA), (4) Psychological
Impact of Dental Aesthetics Questionnaire (PIDAQ), (5) Beck Depression Inventory
second edition (BDIII), (6) Rosenberg Self-Esteem Scale (RSES), (7) oral health
status questionnaire (OHSQ), and the 14-item (8) Oral Health Impact Profile
(OHIP-14).
Huang et al. evaluated the changes of oral health-related quality of life (OHRQoL)
and satisfaction between SFOA and conventional jaw surgery and reported that
OHRQoL is significantly improved in SFOA. The study evaluated functional limita-
tion, physical pain, psychological discomfort, physical disability, psychological dis-
ability, social disability, and any handicaps using Dental Impact on Daily Living
(DIDL) questionnaire and reported that [34] SFOA could improve OHRQoL imme-
diately and lead to better satisfaction in the quality of life survey in comparison to
conventional jaw surgery group.
Four systematic and one meta-analysis were conducted to evaluate the current evi-
dence on postoperative stability, efficacy, and surgical results between SFOA and
conventional jaw surgery (Table 13.2) [35–38]. The studies were performed in
accord with recommendations from the Cochrane Collaboration, Quality of
Reporting of Meta-analyses (QUOROM) guidelines, PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-analyses), and PICOS (participants, inter-
vention, comparisons, outcomes, and study design). Electronic searches were made
on PubMed, Embase, and Cochrane Database with Medical Subject Headings
(MeSH) search headings were used surgery first, surgery early, and orthognathic
surgery. Yang et al. concluded that SFOA offers an efficient alternative to conven-
tional jaw surgery with shorter treatment duration, with comparable postoperative
stability. However, SFOA had a longer duration in the post-surgical orthodontic
phase when compared to conventional jaw surgery [35]. Peiro-Guijarro et al. and
Huang et al. noted that SFOA is a new treatment approach which is poised to be
established as a new treatment paradigm for the management of dentomaxillofacial
deformity with studies showing satisfactory outcomes and high acceptance rate
amongst the patients. They deduced that the results should be interpreted with
13.6 Conclusion 157
Table 13.2 Table showing important systematic review, meta-analysis, and randomized con-
trolled trials on SFOA
First author Year Study type Purpose of study Outcome
Le Yang [35] 2017 SR∗ & MAǂ Does the surgery-first SFOA significantly shortens
approach produce better total treatment time, with
outcomes in orthognathic comparable postoperative
surgery? stability
Hongpu Wei 2018 SR & MA Compare the difference in SFOA mandible tends to rotate
[36] postoperative stability counterclockwise more than
between a SFOA and a COA, indicating poor post-op
conventional orthodontics- stability in SFOA than COA
first approach (COA)
Huang CS 2014 SR Appraise the currently Both the surgery-first approach
[37] available evidence on the and orthodontics-first approach
surgery-first approach had similar long-term outcomes
and support its use in in dentofacial relationship
orthognathic surgery
Peiro- 2015 SR Analyse current protocols Reduce total treatment time
Guijarro [38] and results of patients significantly and achieve high
treated with surgery first levels of patient and
and compare the orthodontist satisfaction. Lack
outcomes with a of prospective long-term
conventional approach follow-up
SR Systematic review, ǂMA Meta-analysis
*
caution because of the wide variance of study designs and outcome variables,
reporting biases, and lack of prospective long-term follow-ups [37, 38]. On the con-
trary, Wei et al. suggested that SFOA might yield poorer results especially with the
mandible rotated in a counterclockwise direction leading to worsen relapse rate.
They also noted that their finding largely relies on the currently available data which
might have potential bias as the studies that their meta-analysis included were either
two-dimensional assessment studies using lateral cephalometric radiographs. Some
of these studies are retrospective with selection bias. Credible evidence needs to be
gathered in the field of health resource utilization of SFOA (in terms of hospitaliza-
tion/ward; manpower, planning, execution, lab procedures; and equipment; soft-
wares, navigation, and 3D printers).
13.6 Conclusion
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Future of Surgery-First Orthognathic
Approach 14
14.1 Introduction
Recently, 3D imaging has found an enormous growth and refinement in the field of
medical computed tomography (CT) imaging. Cone beam computed tomography
(CBCT) has gained popularity in terms of acquiring volumetric data as it allows
3D photos Creation of
CBCT Scan ‘Composite Model’
+ (3D Soft tissue+
3dMD face system
Trios 3 Shape Scan 3D Dentition+
(3dMD Inc.)
3D Skeleton)
3D printed splint
+
3D Surgical Navigation
Fig. 14.1 Flow chart explaining the 3D image acquisition, creation of composite model, and
execution of surgery plan for the creation of 3D-printed surgical splints and 3D surgical
navigation
precise 3D reconstruction with reduced radiation dosage with a short scanning time
and at an affordable cost [8, 9]. Surface data capture technology has also evolved
[10]. Non-contact surface scanning like 3D laser scanners (Konica Minolta Vivid
910, Tokyo, Japan) and 3D photogrammetry (3dMD Face System, 3dMD Inc.,
Atlanta, GA, USA) are some of the surface image acquiring technologies that allow
the surface data acquisition of the soft tissue using high-speed and high-resolution
data capturing algorithms. 3D laser scanners and synchronized multi-cameras of 3D
photogrammetry not only integrate the missing link (i.e. soft tissue) of CBCT but
also enable the end user to better simulate the soft tissue responses to osseous move-
ments during virtual surgical planning [11, 12] (Table 14.1). The current soft tissue
capturing modalities rely on computing algorithms for soft tissue simulations, such
as the mass spring model, the finite-element model, and the mass tensor model with
a high level of prediction accuracy (100% for upper lip, 98% for lower lip, etc.) [13,
14]. Furthermore, there is the ability for the integration of hard tissue scan and soft
tissue surface images which can be superimposed three-dimensionally. The 3D
superimposition of dental arches is recommended as the CT images might show
‘metal streak artefact’ in the teeth area, due to orthodontic brackets or metallic res-
toration, and prosthodontic work (prosthodontics crowns, implants, etc.). To mini-
mize or eliminate the metal streak artefact, it is essential to replace the distorted CT
images such that a clear region is obtained for efficient viewing, planning, and pro-
duction of accurate surgical splints. Although newer CBCT machines have an
Table 14.1 Recent advances in jaw surgery management software
Sr. Free to
No. Software name Company Highlight Website use?
1 NemoFAB 3D Software Nemotec • Surgery simulation and able to predict http://nemotecstore.com/product/ No
S.L. postoperative outcomes nemoceph-fab-3d/
• Produce CAD/CAM surgical splints to
avoid errors in the traditional model
process
2 Dolphin 3D Surgery Dolphin Imaging & • Ability to merge a CBCT volume scan, http://www.dolphinimaging.com/product/ No
(v11.8) Management digital study model, and face photo to ThreeD#3D_Surgery
Solutions perform a 3D virtual surgery workup
• Digital study model software allows
seamless integration with CEREC Ortho
software
14.2 3D Image Acquisition and Diagnosis
Sr. Free to
No. Software name Company Highlight Website use?
7 Tx STUDIO™ (v5.4) i-CAT • Conveniently order surgical guides http://www.i-cat.com/products/i-cat-software/ No
through the Tx STUDIO software
• Automatic nerve canal tracing
8 Planmeca Romexis® Planmeca • Best compatibility with other systems http://www.planmeca.com/Software/Desktop/ No
• Mobile app allows viewing of 2D and Planmeca-Romexis/
3D images on mobile phone
9 CS 3D Imaging Carestream dental • Comprehensive assessment of dental and http://carestreamdental.com/us/en/ No
Software skeletal landmarks imagingsoftware/3D-Software
• Design custom appliances and image-
guided treatment
10 3D Slicer (v4.6) Kitware Inc. • Open-source software platform available https://www.slicer.org/ Yes
on Linux, Mac OS X, and Windows (Open
• Multimodality imaging includes MRI, source)
CT, US, and microscopy
• No restriction on use as it is intended for
research
11 Image J ImageJ developers • Java-based open-source software— http://imagej.net Yes
compatible on all major platforms (Open
• World’s fastest pure Java image source)
processing program
12 ITK-SNAP (v3.6.0) ITK-SNAP • Clean user interface http://www.itksnap.org/ Yes
• Active online forum provides support for (Open
both users and developers source)
13 iPlan CMF Brainlab • Easy correction of improperly positioned https://www.brainlab.com/en/surgery- No
patient scans products/overview-ent-cmf-products/
• Structures can be easily mirrored from iplan-cmf-straightforward-planning-and-
the healthy onto the defective side navigation/
14 Future of Surgery-First Orthognathic Approach
Sr. Free to
No. Software name Company Highlight Website use?
14 MATLAB® MathWorks • Able to develop, test, refine, and https://www.mathworks.com/solutions/ No
implement algorithms to improve image medical-devices/medical-imaging.html
processing workflow
15 Mimics Care Suite Materialise • Plan for orthognathic procedures and http://www.materialise.com/en/medical/ No
soft tissue simulations mimics-care-suite
16 Konica Minolta Vivid Konica Minolta • Generation of design CAD data from http://sensing.konicaminolta.us/ No
910 3D Laser physical models
Scanner • Capture of data for finite-element
analysis
• High-speed scan time (77,000 points in
0.3 s)
17 Amira Visage imaging Inc., • 3D reconstruction Thermofisher.com/Amira-avizo No
14.2 3D Image Acquisition and Diagnosis
Sr. Free to
No. Software name Company Highlight Website use?
22 Surgicase CMF Materialise, Leuven, • Image segmentation system www.materialise.com No
Belgium • Simulating/evaluating surgical treatment
options
23 Avizo FEI Visualization • 2D/3D alignment of image slices www.vsg3d.com No
Sciences Group • Surface and volume meshes generation
• Interactive visualization
• Soft tissue deformation simulation
24 3Diagnosys 3diemme, Cantu, • 3D viewing, diagnostics, and 3D www.3diemme.it No
Italy simulation
• Surgical planning
25 OnDemand3D CyberMed, Seoul, • Surgical replica for precise treatment www.ondemand3d.com No
Republic of Korea planning
• Customized template
26 Blender Blender Foundation • High-end 3D software www.blender.org Yes
• Digital sculpting (Open
• Real-time control and rendering source)
• Camera and object tracking
27 InVesalius3 InVesalius • CT image reconstruction www.cti.gov.br/en/invesalius Yes
• Magnetic resonance images (Open
reconstruction source)
14 Future of Surgery-First Orthognathic Approach
14.3 Virtual Surgical Planning (VSP) 167
inbuilt metal deletion technique (MDT) that automatically reduces artefacts ema-
nating from the aforementioned reasons, it is still prudent to incorporate an intra-
oral scanner (TRIOS® 3 shape Copenhagen, Denmark) to scan the intra-oral l region
and superimpose the intra-oral scan on the CT scans. Several intra-oral scanners are
available for the recordings of the dental arches. All three imaging modalities such
as CBCT (for osseous structure scan), 3D photogrammetry/non-contact laser scan-
ner (for soft tissue scan), and intra-oral scan (for dental arches) are superimposed
and registered for the creation of a virtual ‘composite maxillofacial-dental’ [15] or
a ‘skull-dental composite’ [16] 3D working model. Subsequently, ‘virtual surgical
planning’ is carried out on the composite model.
The VSP software can be seamlessly integrated into the computer networks
across the hospital or teaching institutions such that the ‘surgical plan’ can be
remotely accessed by the surgeon in the operating room and viewed in the clinic to
Fig. 14.2 VSP seamlessly integrates soft tissue and hard tissue and allows execution of planned
surgery. Also, 3D surgical splint design can be visualized for ‘accuracy and fit’ before the 3D
splints are printed
168
Photogrammetry System
CBCT scan
Immediate post-surgery Outcome 3D printed Wafer 3D Printer-Steriolithography System Virtual Splint/Surgical Wafer
14 Future of Surgery-First Orthognathic Approach
inform the patient and in the classrooms for training and education. VSP allows the
surgeon to visualize and prepare for the potential difficulties that might be encoun-
tered during the actual surgery, thereby reducing the possible surgical complications
and post-surgical morbidity [3, 8, 17]. VSP significantly reduces the time required
for treatment planning of jaw surgery cases to as much as 91% in comparison to
non-digital surgical planning methods [18].
Pascal et al. described ‘transfer methods or tools’ available for surgical planning
into six categories, namely, (1) freehand surgery, (2) traditional handmade acrylic
splints (HMAS), (3) CAD/CAM splints, (4) CAD/CAM splints with extra-oral
bone-borne support (EOBS) or custom-made fixation miniplates (CFMP), and (5)
surgical navigation CAD/CAM splints [19]. Once the final surgical plan is estab-
lished, the construction of surgical splints could either be done by analogue method
or digital-assisted method. The ‘digital surgical splints’ are transferred to a stereo-
lithography (STL) file format for the creation/printing of actual surgical splints. The
STL is a commonly used computer-aided design (CAD) format for rapid prototyp-
ing, 3D printing, and computer-aided manufacturing (CAM) [17, 20]. Several 3D
printers are commercially available for the manufacturing of surgical splints, such
as Stratasys (Stratasys, MN, USA), voxel 8 (Voxel 8, Suite 8 Somerville, MA,
USA), Simplify3D software (Cincinnati, OH, USA), Three D Systems software (3D
Systems Corporation, USA), and Tizian Creativ RT (Schutz Dental, Rosbach vor
der Hohe, Germany). The printed surgical splints are used in the operating theatre
for fixation of the planned osteotomy and the positioning of the jaw.
Jaw surgery performed using surgical splint with extra-oral bone-borne support
(EOBS) holds an important place for surgery-first orthognathic approach for the
following reasons:
Free
Sr. Name of the navigation to
No. system platform Company Highlight Website use?
6 Vector vision Brainlab, Westchester, IL • Optical tracking system www.brainlab.com No
• Contoured-based registration
• Paired-point registration
7 Instatrak GE Health Care, Buckinghamshire, UK • Global positioning system www.gehealthcare.com No
• Uses optical technology to locate
surgical instrument in 3D space
8 VoNaviX (IVS Renishaw Innovation • Stereotactic angular and spatial www.renishaw.com/neuro No
Solutions, Chemnitz, positioning of surgical instruments
Germany)
14 Future of Surgery-First Orthognathic Approach
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