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MOO 250409

REVIEW

CURRENT
OPINION Surgical orthodontics
Alexis M. Strohl and Lauren Vitkus

Purpose of review
The article reviews some commonly used orthodontic treatments as well as new strategies to assist in the
correction of malocclusion. Many techniques are used in conjunction with surgical intervention and are a
necessary compliment to orthognathic surgery. Basic knowledge of these practices will aid in the surgeon’s
ability to adequately treat the patient.
Recent findings
Many orthodontists and surgeons are eliminating presurgical orthodontics to adopt a strategy of ‘surgery
first’ orthodontics in orthognathic surgery. This has the benefit of immediate improvement in facial
aesthetics and shorter treatment times. The advent of virtual surgical planning has helped facilitate the
development of this new paradigm by making surgical planning faster and easier. Furthermore, using
intraoperative surgical navigation is improving overall precision and outcomes.
Summary
A variety of surgical and nonsurgical treatments may be employed in the treatment of malocclusion. It is
important to be familiar with all options available and tailor the patient’s treatment plan accordingly.
Surgery-first orthodontics, intraoperative surgical navigation, virtual surgical planning, and 3D printing are
evolving new techniques that are producing shorter treatment times and subsequently improving patient
satisfaction without sacrificing long-term stability.
Keywords
malocclusion, orthodontics, orthognathic

INTRODUCTION outlines a variety of the techniques that may be used

Malocclusion can be managed by a variety of ortho-
dontic and surgical interventions. At times it is
necessary to combine these strategies to produce
an optimal final outcome. It is important that
orthognathic surgeons understand the complimen-
tary orthodontic treatments being performed to
achieve the best results. Furthermore, an under-
standing of the limitations of each specialty is essen-
tial for an ideal final result and positive
patient experience.
One important concept to grasp is the difference
between orthodontic and orthopedic forces. When
gentle orthodontic forces are applied, the periodontal
ligament continues to receive blood flow and oxygen-
ation, which allows for positive dental changes to
occur. In contrast, when stronger (orthopedic) forces
are applied, blood supply can be cutoff to the perio-
dontal ligament if the forces are not managed prop-
erly. This results in changes to the skeletal structure as
the orthopedic forces change the magnitude and
direction of bone growth and thereby resist dental
change. Depending on the patient’s malocclusion, a
variety of orthodontic and orthopedic changes may
be needed to correct the deformity. This article
by orthodontists to assist in the surgical correction of
malocclusion. These tools can be used in preparation
for orthognathic surgery or as a compliment to
surgical intervention.
TEMPORARY ANCHORAGE DEVICES
The development of temporary anchorage devices
(TADs) has provided another option for anchorage
beyond extraoral headgear or other intraoral appli-
ances, including interarch elastics, the nance appli-
ance, and the lingual arch [1]. In this technique, a
miniscrew made of titanium alloy or stainless steel is
anchored to the palatal or alveolar bone and used to
augment tooth movement [2]. TADs are available in
variable lengths and diameters and the head of the
screw may be either a flat top or a post [2],
Upstate Medical Center, Syracuse, New York, USA
Correspondence to Alexis M. Strohl, MD, Upstate Medical Center, 750 E
Adams St., Syracuse, NY, USA. Tel: +1 315 464 7281;
e-mail: strohla@upstate.edu
Curr Opin Otolaryngol Head Neck Surg 2017, 25:000–000
DOI:10.1097/MOO.0000000000000371

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Maxillofacial surgery
KEY POINTS
 Surgical and nonsurgical orthodontics are an important
compliment to surgery in the treatment of malocclusion.
 Regular communication and planning between the
orthodontist and the surgeon will facilitate overall
treatment and improve outcomes.
 There is a recent paradigm shift from standard
presurgical orthodontics to ‘surgery-first’ orthodontics in
orthognathic surgery.
 Traditional orthognathic cephalometric surgical
planning is being replaced by the advent of VSP and
intraoperative image guidance.
depending on the clinical situation in which it is
used. The implant can be fixed to the bone trans-
osteally, subperiosteally, or endosteally [3] and can
be placed transmucosally in the office with local
anesthesia. The screws are particularly useful for
orthodontic intrusion of teeth, which for example
may help correct an anterior open bite resulting
from premature molar contact. TADs allow for
absolute anchorage in situations where reciprocal
movement of teeth is contraindicated and are help-
ful for more predictable treatment of occlusal cants
[1,2]. The implant is removed once the goal of
placement is accomplished. Risks of this technique
include the implant loosening or breaking, infec-
tion, damage to tooth roots, intrasinus placement,
and mucosal overgrowth [1,2,4].
FUNCTIONAL APPLIANCES
When a skeletal abnormality is noted at a young age,
functional appliances may be utilized in an attempt
to avoid surgical intervention later in life. By defi-
nition, functional appliances produce orthodontic
or orthopedic forces by exploiting the patient’s own
muscle activity.
The Herbst appliance is the most commonly
used fixed functional appliance. It is used in patients
with retrognathia or micrognathia and class II mal-
occlusion to aid in stimulating the subcondylar
growth center and subsequently aid in new bone
growth [5–7]. The appliance is fixed to the upper
and lower molars and is worn 24 h a day. This avoids
the compliance issues that are inherent with remov-
able devices. A piston is adhered to the upper and
lower fixation points and is positioned tangential to
the mandibular dentition on the buccal surface. This
piston can be adjusted to control the relative max-
illomandibular positioning, and ultimately places
forward pull on the mandible to stimulate new bone
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growth. Although the pressure on the maxilla aids in
moving the teeth distally to help to correct class II
malocclusion [8,9], the majority of correction is
because of the development of the lower jaw.
Ideally, the appliance is used in the permanent
dentition but can be used with mixed or deciduous
dentition by adhering the appliance to a permanent
canine or by using a bonded device [8]. Studies have
shown good stability of treatment results with min-
&
imal relapse of effect over time [10 ,11].
PALATAL EXPANSION
Transverse maxillary hypoplasia and posterior lin-
gual crossbite can be managed predictably with
palatal expansion. The palatal suture begins closure
posteriorly with gradual extension anteriorly. It is
estimated to close completely by age 13 in women
and age 15 in men. Recent evidence using cone
beam CT has shown that the timing of palatine
and maxillary suture closure is highly variable and
age is not a reliable determinant [12]. Therefore,
imaging may be helpful in determining the treat-
ment indicated for patients needing transverse
expansion. Depending on the diagnosis and treat-
ment goals, expansion may be undertaken prior to
the eruption of all permanent teeth as part of a first
phase of treatment, often referred to as Phase I
orthodontics, or may be managed in conjunction
with comprehensive orthodontic treatment.
The quad helix expander is an appliance that is
attached to the upper molars and is connected by
four helices across the palate. The appliance is
cemented to the molars in an active state with the
springs providing a constant tension across the pal-
atal suture, creating a slow, steady expansion. The
W-arch is an appliance very similar to the quad
helix, but is designed without the helices. Both
can be used in the mixed dentition [13]. and are
very suitable to use in patients with cleft palate.
These expanders have been shown to be more effec-
tive than removable expansion plates at treating
posterior crossbite [14].
When expansion is undertaken as part of com-
prehensive orthodontic treatment in adolescents in
the late mixed or early permanent dentition, a rapid
palatal expander is typically the expander of choice,
providing many millimeters of sutural expansion in
a relatively short period of time. The expander is
designed to attach to the permanent first molars and
premolars and is split longitudinally down the
middle by an expansion screw. The size of the screws
used is dictated by the clinician, dependent on the
amount of expansion needed, and usually range
from 9 to 13 mm. The screw is typically activated
one to two times daily, with each activation
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providing approximately 0.25 mm of expansion.
The activation period lasts between 2 and 3 weeks
until ideal expansion is achieved. Following treat-
ment, the appliance is retained in the mouth 3–6
months to allow bone fill and suture stabilization to
occur [15].
Once the palatal suture has closed, the above
techniques can no longer be used for expansion and
it may be necessary to perform surgical correction.
One option is surgically assisted palatal or maxillary
&
expansion [16 ,17]. In this procedure, a palatal
expander is placed preoperatively and either a uni-
lateral or bilateral LeForte I osteotomy is performed.
The mid-palatal suture may also be separated or
allowed to separate on its own with distraction. This
can be performed with or without pterygoid plate
separation [18]. If the pterygoid plates are separated,
there is increased risk of bleeding because of risk of
injury to the pterygoid plexus and branches of the
internal maxillary artery [19]. Without pterygoid
plate separation, some have shown incomplete cor-
rection of the posterior transverse discrepancy,
whereas others have shown no difference in out-
&
comes [20 ] No strong recommendations for or
against pterygoid plate separation have been made
&
[20 ]. Intraoperatively, the expander is activated 1–
2 mm to begin expansion. Studies have shown that
this technique is stable over time and relapse is
&
minimal [16 ,17,21]. This is in contrast to Le Forte
I segmental osteotomy, where relapse tends to be
greater [18,22]. Maxillary expansion with surgery
tends not to stabilize for 6–8 months [23]. There-
fore, a full-time retainer is necessary during this time
frame to prevent more significant relapse.
PRESURGICAL ORTHODONTICS
Prior to orthognathic surgery for correction of jaw
discrepancies, it is necessary to remove any dental
compensations that have been made over time to
create occlusal contacts. When the jaws are mala-
ligned, the teeth tend to find ways to compensate
to decrease the amount of discrepancy present. If
the dental compensations are not corrected or
accounted-for prior to surgery, the jaw position will
be undercorrected. It is important for the surgeon
and orthodontist to be in communication during
the planning phase, as orthodontic corrections will
vary dependent on the proposed surgical procedure.
Straightening of the dental roots is useful in inter-
dental osteotomies to prevent injury to the roots,
whereas root flaring is preferred for segmental
osteotomy [24]. The ultimate goal of presurgical
orthodontics is to allow for ideal surgical position-
ing of dental segments. If the incisors are not placed
in proper position prior to surgery, it is difficult to
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Surgical orthodontics Strohl and Vitkus
accurately realign the jaws because of dental inter-
ferences present at their new position [23]. Further-
more, proper presurgical orthodontic planning
helps achieve postoperative occlusal stability by
creating maximal occlusal contact [25].
To accomplish the necessary dental movements,
in addition to traditional brackets and wires, some
of the aforementioned techniques may be utilized.
Overall, the more correction that is done preoper-
atively, the more predictable orthodontic treatment
is postoperatively. The standard approach to com-
prehensive surgical–orthodontic management
includes a prolonged presurgical orthodontic phase,
followed by orthognathic surgery with some form of
postoperative stability, followed by a short period of
postoperative orthodontics to fine tune the occlu-
sion [23].
There has been some recent debate as to whether
or not presurgical orthodontics is necessary to
achieve optimal outcomes. A 2010 retrospective
review by Liao et al. compared two similar groups
of class III anterior open-bite patients [26]. One
group received presurgical orthodontics and the
other did not. They found that there was no signifi-
cant difference in facial aesthetics, overbite, peer
assessment rating score, maxillary stability, or hori-
zontal mandibular stability. The presurgical ortho-
dontic group had significantly less overjet, although
the opposing group was still within a normal range.
There was noted to be a significantly longer treat-
ment time with presurgical orthodontics. Based on
this evidence they questioned the necessity for pre-
surgical orthodontics [26].
SURGERY-FIRST ORTHODONTICS
Recent literature supports Liao et al. s [26] theory
that there may be benefit to foregoing presurgical
orthodontics and beginning treatment with orthog-
nathic surgery. The concept was first proposed by
Nagasaka et al. in 2009 [27]. Hernández-Alfaro et al.
[28] confirmed that this technique is feasible in a
prospective study of 45 patients successfully treated
with surgery-first orthodontics. Presurgical ortho-
dontics can take up to 24 months to complete prior
to surgery [28]. In this technique, the patient
achieves immediate improvement of dental func-
tion and facial aesthetics with the potential for
shorter treatment times [23,25]. Facial aesthetics
are often the primary concern of the patient [28],
and therefore surgically correcting the general facial
aesthetic at the start of treatment positively affects
the patient’s overall satisfaction [27]. This procedure
requires rigid stability postoperatively to prevent
significant relapse of movement. It also necessitates
the surgeon to perform surgery on malaligned
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Maxillofacial surgery
dental arches. This can make the surgery more com-
plicated and requires significant surgical skill and
familiarity. Furthermore, the surgeon needs to cre-
ate an occlusion that is treatable with orthodontics
alone. For this reason, it is imperative that the
surgeon and the orthodontist work together when
creating the patient’s treatment plan to ensure an
optimal final occlusion.
Typically, brackets and archwires are placed
prior to surgery so that treatment can be initiated
immediately after surgery [26]. TADs may also be
required in the posttreatment phase to correct
tooth position. The unlocked occlusion and lack
of opposing soft tissue and mucular forces [28,29]
allows for rapid tooth movement to achieve align-
ment, leveling, and coordination [26]. Further-
more, greater postoperative metabolic turnover
accelerates tooth movement, decreasing treatment
times [28–31]. For this reason, some surgeons advo-
cate performing dentoalveolar corticotomies to aid
in tooth movement and to decrease treatment times
[28]. This technique is borrowed from surgically
facilitated orthodontic treatment, where small per-
forations in the cortical bone are made around
individual teeth, leaving trabecular bone intact.
Orthodontic forces are initiated shortly after
surgery to achieve dental movement and bony
remodeling [32]. This has been shown to produce
faster and more stable results [33]. A recent system-
atic review confirmed that this is a well tolerated
technique and that there is moderate-quality evi-
dence to support a temporary phase of accelerated
tooth movement that can be used to create more-
rapid positive dental changes [32].
Surgery-first orthodontics has been gaining
recent interest. The potential decrease in treatment
time is especially attractive as new strategies are
developed to decrease overall treatment times for
orthodontics in general [32,34].
VIRTUAL SURGICAL PLANNING
There are six degrees of freedom of the dental com-
plex that need to be taken into account when
orthodontic/orthognathic movement is being con-
sidered [23]. Historically, two-dimensional radio-
graphs and hand-drawn cephalometrics, in
combination with articulator-mounted casts were
used to construct the treatment guide. This method
is still used among many surgeons today. There are
many deficiencies with this technique including the
inability to address facial asymmetries and the dif-
fusion of landmarks because of structures overlap-
ping on radiographs [35]. With the widespread
availability of computed tomography, three-dimen-
sional imaging and computer-assisted virtual
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surgical planning (VSP) has become popular. In
severe malocclusion, three-dimensional imaging
has become standard of care [23].
There are three distinct advantages to using VSP.
The first is that multiple different surgical outcomes
can be visualized by easily manipulating different
segments in different directions without having to
actually perform repeated model surgeries. It also
allows the surgeon to visualize the amount of con-
dylar torque that is created with the positioning in
an effort to minimize condylar strain. Last, it allows
the surgeon to easily create anatomically corrected
surgical splints as opposed to creating them from the
repositioned dental casts [23]. Three-dimensional
printing has become widely available and can be
used to produce splints based on VSP plans. In a
prospective study by Zinser et al. [35], the use of
computer-aided designed and manufactured splints
had the highest precision for maxillary planning
transfer in comparison with traditional splinting
or surgical navigation.
Intraoperative surgical navigation has been
employed to assist in precise movement of the
maxilla/mandible in accordance with the predeter-
mined surgical plan. Excellent results have been
seen with transverse movements but there is
increased error noted in vertical changes. The nav-
igation must be set up using surface landmarks
preoperatively with minimal error. If the system is
not perfectly matched, discrepancies are likely. This
relatively new technique is gaining interest as a way
to avoid intraoperative splinting to achieve the
desired results [35].
CONCLUSION
Surgical orthodontics is an evolving field that uti-
lizes a variety of old and new techniques to correct a
range of malocclusion. It is important to be aware of
the array of options available to patients of different
ages with varying pathology. This will ensure that
the proper treatments can be initiated at the appro-
priate times. Without this information, patients
may require surgery at an older age that could have
been avoided with orthodontics at an earlier stage.
Communication among providers is imperative to
achieve optimal results. Orthodontics and orthog-
nathic surgery have limitations to what they can
address independently. Orthodontic treatment is a
necessary compliment to orthognathic surgery,
both in its pretreatment role to remove dental com-
pensations and its posttreatment role in fine tuning
the occlusion. The advent of ‘surgery-first’ ortho-
dontics is bringing new ideas and treatment strat-
egies to the field. Furthermore, with three-
dimensional imaging becoming more widely
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MOO 250409
available, surgical and orthodontic planning is
faster and more facile. As more knowledge is gained,
outcomes will continue to improve with better
patient satisfaction scores and decreased treatment
times, likely translating to better overall patient care
and outcomes in the future.
Acknowledgements
We would like to thank Dr Sherard A. Tatum, Dr Ronald
Bellohusen, and Dr Robert P. Bellohusen for their assist-
ance with this review.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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