Orthognathicsurgeryand Orthodontics: Inadequate Planning Leading To Complications or Unfavorable Results

O r t h o g n a t h i c S u r g e r y an d
Orthodontics
Inadequate Planning Leading to
Complications or Unfavorable Results
Katherine P. Klein, DMD, MSa,*, Leonard B. Kaban, DMD, MDa,
Mohamed I. Masoud, BDS, DMScb
KEYWORDS
Orthodontics Orthognathic surgery Complications Unfavorable results
KEY POINTS
Overall goals and a coordinated surgical/orthodontic plan should be developed and agreed upon
by the orthodontist/surgeon team and approved by the patient before the start of treatment.
Continuous communication between the orthodontist and surgeon through all phases of treatment
is essential to minimize complications or unfavorable outcomes.
Preoperative orthodontic treatment progress should be monitored by the surgeon every 4 to
6 months and discussed with the orthodontist.
Frequent progress models to assess tooth position and arch compatibility are recommended.
Inadequate preoperative planning may necessitate delay or alteration of the ideal surgical plan.
INTRODUCTION decompensation, increased treatment time, delay,

or potentially an increase in magnitude of the oper-
Inadequate and inappropriate presurgical treat- ation (eg, turning what could be a single-jaw into a
ment planning are commonly the source of unfa- 2-jaw procedure).6–8
vorable outcomes or complications in patients Identifying common pitfalls in orthognathic sur-
undergoing orthognathic surgery.1–5 It is critical gical cases6–27 and developing a systematic
that the patient’s chief complaint, treatment goals, approach to address potential missteps are
and expectations are established and understood essential for treatment success. Most errors can
by the clinicians. The diagnosis, orthodontic, and be classified into 4 general categories:
surgical goals and the overall plan should be dis-
cussed and agreed upon by the surgeon and 1. Complications related to treatment planning
orthodontist before beginning treatment.1–5 When 2. Complications related to inadequate dental
possible, the need for orthognathic surgery should decompensation
be determined before any tooth movement 3. Complications related to appliances
has been started so that orthodontic treatment 4. Complications related to postsurgical ortho-
can be accomplished as efficiently and effectively dontic care
oralmaxsurgery.theclinics.com
as possible.1–5 Miscommunication between pro-

viders can result in improper or insufficient dental When orthodontists and surgeons work together
to formulate a proper diagnosis and treatment
a
Massachusetts General Hospital, OMFS Academic Offices, Warren 1201, 55 Fruit Street, Boston, MA 02114,
USA; b Department of Developmental Biology, Harvard School of Dental Medicine, 188 Longwood Avenue,
Boston, MA 02115, USA
* Corresponding author.
E-mail address: Kklein1@mgh.harvard.edu
Oral Maxillofacial Surg Clin N Am 32 (2020) 71–82

https://doi.org/10.1016/j.coms.2019.08.008
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72 Klein et al
plan, monitor and give feedback to each other Table 1

throughout the preoperative orthodontic process, Massachusetts General Hospital surgical
and agree on the use of appropriate appliances orthodontic patient pretreatment checklist
and postsurgical treatment strategies, patients
will have the best chance for a successful U Has the patient’s chief complaint been
outcome.1–5 identified?
U Are the names and contact information of
COMPLICATIONS RELATED TO TREATMENT the patient’s treatment team (oral and
maxillofacial surgeon, orthodontist,
PLANNING
dentist) in the chart?
Before treatment begins, the patient, orthodon- U Have pretreatment records been analyzed?
tist, and surgeon should all agree on the dental U Are there any dental pathologic conditions
and skeletal diagnosis and a conceptual surgical (caries and similar) that need to be
and orthodontic plan. The orthodontist and sur- addressed immediately? Do third molars
geon should feel comfortable that the patient need to be extracted before the
has an understanding of the goals and reason- operation?
able expectations regarding the predicted U Meet with the team and finalize the dental
esthetic and functional outcomes. The Orthog- and skeletal diagnosis and global
nathic Surgical Team at Massachusetts General treatment plan (1 jaw vs 2 jaws, midline
rotations, presurgical position of
Hospital (MGH) meets once each week for initial
incisors). Has the final plan been
case presentations, progress evaluations as
documented in the chart and
necessary, assessment of immediate postopera- communicated to the patient?
tive outcomes, discussion of complications, and
U When does the patient want the
long-term follow-up evaluations. There is a stan- operation? Is there a major life event/
dardized format for presentation and a system- deadline that we must work around
atic process to evaluate each patient. The (wedding, pregnancy, patient moving,
authors review a checklist to mitigate the risk insurance expiring, and so forth)?
of overlooking an important diagnostic or treat- U What orthodontic appliances will be used
ment detail (Table 1). (metal braces, clear braces, clear
When treatment goals are not clear, tooth aligners, and so forth)? What
movement may be carried out in the wrong downstream implications will this have
direction. For example, if an orthodontist at- for the presurgery setup?
tempts to further compensate the teeth to “mini- U Has the patient signed the informed
mize the magnitude” of the operation, this may consent?
have to be reversed to accomplish the desired U When will the other providers see the
anatomic or esthetic outcome. Orthodontic patient for follow-up appointments?
treatment time will be extended; the operative
Developing a systematic process to evaluate and manage
plan may have to be changed, or the outcome each surgical-orthodontic patient is key to effective and
may be less than ideal. Ultimately this will efficient treatment.
result in increased anxiety and frustration for
all members of the treatment team and the
Complications Related to Inadequate
patient.
Orthodontic Decompensation in the Sagittal
Plane
COMPLICATIONS RELATED TO PRESURGICAL
ORTHODONTIC TREATMENT Patients with class III malocclusions often have
physiologic dental compensations in an attempt
The objectives for presurgical orthodontic treat- to improve function and occlusal intercuspation.
ment are (1) to decompensate the teeth to make These compensations result in proclined upper in-
the magnitude of the dental discrepancy as close cisors (tongue function), retroclined lower incisors
to the skeletal discrepancy as possible. This re- (orbicularis), and lingually tipped lower posterior
quires dental decompensation in the sagittal, ver- teeth (buccinator). The anterior crossbite is there-
tical, and transverse planes; (2) to eliminate dental fore significantly smaller than the skeletal defor-
interferences that would prevent achieving the mity in the sagittal plane, and the transverse
desired final occlusion; and (3) to address tooth- discrepancy may be masked. The presurgical or-
size discrepancies that would prevent interdigita- thodontic objective is usually to procline the lower
tion at the desired postoperative overjet and incisors, upright the mandibular posterior teeth,
overbite. and retrocline the upper incisors. This often
Orthognathic Surgery and Orthodontics 73
involves treating a crowded lower arch without ex- Care must be taken to avoid over-retroclining
tractions (Fig. 1). The position of the lower lip and the upper incisors because that can lead to unsat-
the lower incisors relative to the chin should be isfactory seating of the buccal segments.6–9 Upper
evaluated to avoid moving the lower incisors too incisor control can be achieved using larger wires
far anteriorly, which may compromise their peri- with torque, accentuated curves, and torquing
odontal support and their relationship to the chin auxiliaries when necessary.
(too far forward). If this cannot be avoided, an Patients with class II malocclusions often have
advancement genioplasty may be required to retroclined upper incisors and proclined lower in-
achieve the desired facial esthetics. cisors that limit the magnitude of mandibular
The maxillary arch, on the other hand, often re- movement and prevent the achievement of an
quires extraction even in the absence of crowding orthognathic profile. Orthodontic decompensa-
to create space to decompensate the upper teeth. tion often involves proclination of the upper inci-
This may involve extraction of the upper premolars sors and retroclination of the lower incisors to
(Fig. 2) or distalizing into the space of the extracted maximize the overjet, the surgical advancement
third molars. Distalizing the upper buccal segments of the mandible, and the improvement of chin
can be challenging and often involves temporary projection relative to the lower lip. Fig. 3 shows
anchorage devices or fixed class II bite correctors a case with mandibular hypoplasia and severe
if compliance with class II elastics is not optimal. retroclination of the upper incisors. Despite the
The latter approach can only achieve a minimal severe upper crowding, the upper arch was
amount of upper incisor retraction and is useful in treated with proclination instead of extractions
cases where a smaller surgical movement is to improve the upper incisor inclination. The pa-
planned because the patient has petite features. tient was treated with clear aligners, which are
Fig. 1. The patient was planned for a Le Fort I maxillary advancement. Notice how the bite and lower lip position
“worsen” as the teeth are aligned. Patients should be adequately prepared for the profile changes that are asso-
ciated with orthodontic decompensation.
74 Klein et al
Fig. 2. The patient was planned for a Le Fort I maxillary advancement with extractions of 2 maxillary premolars.
The maxillary arch required extraction of premolars even in the absence of crowding to create space to decom-
pensate the upper teeth. In the cephalometric superimpositions, note the retroclination of the upper incisors and
the proclination of the lower incisors. If teeth are not adequately decompensated, the desired postsurgical facial
outcome cannot be achieved.
less effective than traditional braces at torquing (Fig. 4). The orthodontist should avoid any anterior
the upper incisors. This resulted in only partial elastics and use curved wires to maintain or exag-
decompensation of their position and a gerate the initial open bite. If a biplanar occlusion
less than ideal amount of mandibular is present and the surgeon is planning on seg-
advancement. menting the maxilla, segmental wires should be
used instead of continuous wires. The anterior
Complications Related to Inadequate segmental may or not include the upper canines
Orthodontic Decompensation in the Vertical depending on whether the surgeon is planning to
Plane make the osteotomies between the lateral incisors
A common mistake during presurgical orthodontic and canines or between the canines and first
treatment is to inadvertently close or reduce an premolars.
open bite by extruding the incisors when engaging Hypodivergent patients with a short lower
a continuous wire to level and align the arches anterior face height often have an accentuated
Fig. 3. When teeth are not fully decompensated before surgery, less mandibular advancement is possible.
Fig. 4. A common presurgical orthodontic mistake is to level a biplanar maxillary dental malocclusion with a
continuous archwire.
mandibular curve of Spee with a deep impinging Complications Related to Inadequate

overbite and a thick soft tissue chin button. Orthodontic Decompensation in the
Leveling the lower occlusal plane on these pa- Transverse Plane
tients is another common mistake because it
Patients with maxillary constrictions often have
dentally opens the bite, reduces the vertical dis-
buccally flared upper molars and lingually inclined
tance from the lower incisal edge to menton, and
lower molars. If a 2-piece Le Fort I is planned, the
results in a straight horizontal mandibular
presurgical orthodontic treatment should tip the
advancement, making the chin too prominent
crowns of the upper molars to the palatal and the
and not increasing the lower anterior face height.
crowns of the lower molars to the buccal. This
In these cases, if the accentuated curve of Spee
will tend to create space in the lower arch and
is maintained, during the preoperative orthodon-
require space in the upper arch so this should be
tic treatment, the mandible can be advanced and
considered when assessing the crowding or
rotated in a clockwise rotation, thereby
spacing. If surgically assisted maxillary expansion
increasing the occlusal plane and the lower ante-
is planned before orthodontic treatment, the
rior face height. The patient may not need a
expansion screw should be activated enough to
maxillary osteotomy. Once the curve of Spee is
put the molars in a buccal crossbite tendency.
leveled, the patient will be obligated to a maxil-
This is necessary to make up for normalizing the
lary operation to increase the occlusal plane
inclination of the molars as well as potential
and to allow clockwise rotation of the maxilla
relapse of the procedure. The space created dur-
and mandible.
ing surgically assisted expansion needs to be
Maintaining the deep lower curve of Spee dur-
taken into consideration and can be used to help
ing presurgical orthodontics using curved wires
tip the crowns of the upper molars palatally and
and setting the patient in a tripoded occlusion
relieve existing crowding in the upper arch. Failure
can help avoid these issues. The curve of Spee
to overcorrect the posterior crossbite during surgi-
can be leveled after surgery by allowing the pre-
cally assisted maxillary expansion can result in
molars to erupt. Fig. 5A shows a patient with a
recurrence of the posterior crossbite after the
hypoplastic mandible and a reduced lower ante-
teeth are bonded, and the inclination of the molars
rior facial height. Because the upper incisors did
is normalized. Some patients have significant
not require decompensation and the lower arch
maxillary constriction paired with a narrow
naturally had a deep curve of Spee, it was a suit-
mandible and no crossbite. These cases often
able case for surgery before orthodontic treat-
require surgically assisted expansion of the maxilla
ment. A surgical splint was provided to the
and widening of the mandible by midline distrac-
surgeon to set the lower jaw in a tripod occlusion
tion osteogenesis. This is to avoid developing a
with 2 mm of overjet and overbite. After the oper-
buccal crossbite when the maxillary constriction
ation, the acrylic opposing the premolars was
is corrected. The space created in the mandible
trimmed and elastics to the lower premolars
using surgically assisted expansion can often be
were used to extrude the lower premolars and
sufficient to resolve even severe crowding in the
level the lower curve of Spee while maintaining
lower arch (Fig. 6).
the distance from the lower incisal edges to the
In patients with significant mandibular asymme-
menton (Fig. 5B, C).
try, presurgical orthodontic treatment focuses on
76 Klein et al
Fig. 5. (A) This individual has a hypoplastic mandible and a reduced lower anterior face height. Be-cause of the pro-
clined lower incisors and already present curve of Spee, she was planned for surgery first. (B) Postsurgical result. Or-
thodontic treatment with clear aligners was initiated after surgery. Note the attachments and temporary anchorage
devices used to extrude the man-dibular premolars and level the curve of Spee. (C) Final result after surgery first fol-
lowed by orthodontic tre-atment.
Fig. 6. This individual had a surgically assisted expansion of the maxilla and widening of the mandible by midline
distraction. Note the large midline diastema and how mandibular crowding was alleviated.
decompensation in the axial or transverse plane to teeth were not sufficiently decompensated in the
get the lower dental midline to be coincident with sagittal plane. Extracting the upper premolars
the chin point, exaggerating or creating a lingual allowed full decompensation of the upper incisors,
crossbite on the shorter side of the mandible, creating a large anterior crossbite preoperatively.
and exaggerating or creating a buccal crossbite The posttreatment photographs show the molars
on the longer side of the mandible (Fig. 7). Failure set in a class II relationship with a normal anterior
to accomplish this decompensation will result in relationship and no posterior crossbite, despite
inadequate correction of the asymmetry when the fact that the patient had a 1-piece maxillary
the anatomic position of the mandible is guided osteotomy.
by the occlusion. Conversely, the occlusion will Likewise, the surgical sagittal correction of a
not fit correctly if the final surgical position is set class II malocclusion can often exaggerate a trans-
to put the chin point coincident with the facial verse skeletal discrepancy because it results in a
midline (Fig. 8). wider part of the mandible occluding with a nar-
The surgical correction of a skeletal III malocclu- rower part of the maxilla (Fig. 9).
sion by maxillary advancement and/or mandibular
setback can often resolve a presurgical transverse Complications Related to Adequately
discrepancy because the movement in the sagittal Addressing Dental Interferences and Tooth
plane results in a wider part of the upper arch Size Discrepancies
occluding with a narrower part of the lower arch.
The greater the necessary sagittal surgical correc- Surgical patients often spend years functioning
tion, the less likely surgical intervention will be out of an ideal occlusion and develop wear pat-
needed to correct the transverse relationship. terns that result in significant prematurities when
The case in Fig. 2 had a crossbite before treatment the teeth are articulated in the desired postopera-
and would have needed a 2-piece Le Fort I if the tive position. During the final months of presurgical
orthodontic treatment, impressions should be
78
Fig. 7. This individual has significant mandibular asymmetry. To properly decompensate teeth in preparation for
surgery, a lingual crossbite needs to be created on the shorter side of the mandible, and a buccal crossbite on the
longer side of the mandible. The goal is to decompensate the teeth in the axial or transverse plane and get the
lower dental midline to be coincident with the chin point.
Fig. 8. This individual had inadequate orthodontic decompensation before surgery. Even after bimaxillary sur-
gery, she needed a genioplasty to correctly align her chin with her facial midline.
Fig. 9. Patients with a class II phenotype frequently also have a transverse maxillary deficiency. Note how models
show a posterior crossbite when a class I canine and molar relationship is visualized. This diagnosis should ideally
be noted before the start of orthodontic treatment so decisions can be made about appropriate appliance selec-
tion (palate expander) or surgical plan.
taken every visit to check the bite and perform the overbite during the operation. This puts the sur-
necessary detailing and occlusal adjustment to geon in the difficult position of having to decide
achieve a stable postoperative bite (Fig. 10). between setting the bite with an ideal canine rela-
Similarly, tooth size discrepancies like under- tionship and little or no overjet or setting the bite
sized upper lateral incisors or large lower anterior at the correct overjet and class II buccal seg-
teeth need to be addressed before the surgical ments (Fig. 11).
procedure because they prevent the buccal seg- These problems can be identified by performing
ments from seating at a normal overjet and a tooth size discrepancy analysis and checking the
Fig. 10. When preparing an orthodontic patient for surgery, taking an adequate number study models is essen-
tial. Study models are often taken before every visit and serve as a powerful tool that allows the orthodontist to
both modify wear facets from occlusal prematurities owing to years functioning out of the ideal occlusion, and
detail and finish the bite. This careful presurgical preparation prevents the surgeon from needing to perform
extensive occlusal adjustment during the operation.
80 Klein et al
Fig. 11. During the pretreatment diagnostic workup, it was noted that this patient had a Bolton tooth size
discrepancy in the maxillary anterior arch (small lateral incisors). Orthodontists should manage the tooth size
discrepancy presurgically and either leave space for the ideal buildup or adjust the size of the teeth in the lower
arch before the operation. When a tooth size analysis in not performed and the small tooth size is not taken into
account, the buccal segments will not fit in an ideal Angle class I relationship.
presurgical models for fit. If the canines cannot be

positioned in class I without the incisors being
edge to edge or very shallow, lower incisor inter-
proximal reduction should performed and/or
spaces for upper lateral incisor build-ups should
be opened.
COMPLICATIONS RELATED TO APPLIANCES

Orthodontists use a variety of appliances to align
teeth in preparation for orthognathic surgery: tradi-
tional braces, lingual braces, and clear aligner sys-
tems. With traditional braces, the ideal presurgical
orthognathic setup includes brackets on the facial
surfaces of teeth tied with stainless steel ligatures;
Fig. 12. During surgery, a bracket was broken off the a full-dimension stainless steel arch wire, which
maxillary second molar. The arrow points to the has been inactive for 2 to 3 months; bands on the
bracket which is in the wound. The patient required
first and second molars; and surgical hooks be-
a second operation to retrieve the bracket.
tween all teeth. This orthodontic setup gives the
surgeon maximum flexibility in the operating room
to use the orthodontic appliances to attach splints
and accomplish necessary surgical movements.
Fig. 13. (A) An ideal presurgical orthodontic setup in traditional braces includes full-dimension stainless steel arch
wires, bands on first and second molars, ligature ties on all teeth, and surgical hooks. (B) An ideal presurgical or-
thodontic setup using clear aligners includes attachments on teeth that will need elastics after surgery. The au-
thors’ center prefers the use of metal buttons in case one is dislodged during the operation; it is easier to find
with the use of radiographs.
Fig. 14. This individual failed to return for appropriate postsurgical appointments with both the orthodontist
and surgeon. During this 8-week period, she wore an anterior elastic on the right side only. Note the
dental cant and open bite on the patient’s left. Improper elastic wear can result in distortion of the
dentoalveolar segments and jaw position, turning an excellent postsurgical outcome into a nonideal surgical
result.
In a 2-piece Le Fort operation, surgeons fasten orthodontic care depends on a variety of factors,
wires around the bands on the first molars and including how precise the presurgical orthodontic
pull laterally to separate the maxilla. At the authors’ set up was to the desired result, how close the pre-
institution, there is a higher incidence of brackets dicted surgical plan was to the achieved final sur-
separating from the tooth than bands. When a gical positioning of the jaw or jaws, and the
distal bracket breaks during the operation, it can patient’s level of compliance with elastics after
slide off the wire and disappear into the wound. surgery.
Locating the bracket is difficult and takes addi- At MGH, postoperative patients are followed
tional time under anesthesia, or a second proced- closely by both the surgeon and the orthodontist
ure to remove the lost bracket (Fig. 12). For this to ensure that postoperative directions are being
reason, bands are recommended on distal molars. appropriately observed. Regular checks with
An increasing number of surgical orthodontic both the surgeon and the orthodontist ensure
cases are now treated with clear aligners. When that patients are complying with proper elastic
using clear aligners, it is important to provide the wear. Unchecked elastic wear can result in distor-
surgeon with enough attachments so that surgical tion of the dentoalveolar segments and jaw posi-
splints may be placed, and so that postoperative tion (Fig. 14).
guiding elastics can be used (Fig. 13).
Regardless of the specific material or appliance SUMMARY
that is used, the following 3 guiding principles
should be followed: When orthodontists and surgeons work together
to formulate an accurate diagnosis and treatment
1. No loose brackets or attachments. Appliances plan, monitor and give feedback to each other
need to be firmly attached to teeth to minimize throughout the preoperative and postoperative or-
intraoperative risk. thodontic process, and agree on the use of appro-
2. No tooth movement immediately before sur- priate appliances and postsurgical treatment
gery. Teeth should be stabilized approximately strategies, patients will have the best chance for
8 weeks before surgery with either a stainless a successful outcome.1–4 Miscommunication
steel arch wire or the final aligner. Surgical between providers can result in improper or insuf-
treatment plans are developed based on the ficient dental decompensation, increased treat-
location of the dentition. If dental changes ment time, delay or potentially an increase in
occur before surgery, the dentition may not fit magnitude of the operation (eg, turning what
together as planned intraoperatively, resulting would could be a single-jaw into a 2-jaw proced-
in a nonideal outcome. ure), and a less than satisfactory skeletal and
3. Ample surgical hooks. Surgical hooks are used esthetic result. The authors recommend devel-
intraoperatively to aid in positioning the oping a regular communication schedule between
maxilla and/or the mandible and splint. Place orthodontist and surgeon throughout the entire
ample surgical hooks (between all teeth) to treatment process to avoid errors in treatment
give the surgeon maximum flexibility during planning, inadequate preoperative dental decom-
the operation. pensation of the teeth, complications related to
inadequate or failed orthodontic appliances, and
COMPLICATIONS RELATED TO errors in immediate postoperative orthodontic
POSTSURGICAL ORTHODONTIC CARE management. The authors also recommend
frequent progress dental casts to ensure proper
Careful postsurgical orthodontics is essential for a decompensation of the teeth and adequacy of
successful outcome.1–9 The length of postsurgical the occlusal fit preoperatively, regular
82 Klein et al
communication regarding immediate surgical out- 14. El Deeb M, Wolford L, Bevis R. Complications of
comes relative to planned surgical movements, orthognathic surgery. Clin Plast Surg 1989;16:
frequent communication in the postoperative 825.
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long-term follow-up to critically assess the out- altered sensation and sensory impairment after or-
comes over time. thognathic surgery. Int J Oral Maxillofac Surg
2007;36:577.
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Orthognathicsurgeryand Orthodontics: Inadequate Planning Leading To Complications or Unfavorable Results

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O r t h o g n a t h i c S u r g e r y an d

INTRODUCTION decompensation, increased treatment time, delay,

as possible.1–5 Miscommunication between pro-

Oral Maxillofacial Surg Clin N Am 32 (2020) 71–82

plan, monitor and give feedback to each other Table 1

mandibular curve of Spee with a deep impinging Complications Related to Inadequate

presurgical models for fit. If the canines cannot be

COMPLICATIONS RELATED TO APPLIANCES

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