Surgery-First Orthodontic Management

Surgery-First
Orthodontic
Management
A Clinical Guide to a New

Treatment Approach
Chai Kiat Chng
Narayan H. Gandedkar
Eric J. W. Liou
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
ISBN 978-3-030-18695-1 ISBN 978-3-030-18696-8 (eBook)

https://doi.org/10.1007/978-3-030-18696-8
© Springer Nature Switzerland AG 2019

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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’.
Dedication from Dr. Chai Kiat Chng:

To my beloved parents, for your
unconditional love and support, I am
eternally grateful.
Contents
1 Introduction to Surgery-First Orthognathic Approach (SFOA) �� 1

1.1 Introduction�� 1
1.2 Overview of Surgery-First Orthognathic Approach (SFOA)�� 1
1.3 Revival of Surgery-First Orthognathic Approach �� 4
1.4 Comparison of Conventional and Surgery-First
Orthognathic Approach�� 5
1.5 Conclusion�� 6
References�� 6
2 Diagnosis and Treatment Planning of Surgery-First
2.2 Orthodontic and Surgical Considerations: Case Selection and
Guidelines �� 7
2.2.1 Orthodontic-Driven�� 10
2.2.2 Surgery-Driven�� 10
2.2.3 One Patient Two Problem Concept �� 10
2.3 Conventional Jaw Surgery Planning: Paper Surgery and
Model Surgery�� 10
2.4 3D Virtual Surgical Planning and 3D Splint Fabrication�� 13
References�� 14
3 Biological Principles and Responses to Surgery-First
3.2 Regional Acceleratory Phenomenon�� 15
3.2.1 Systemic Acceleratory Phenomenon (SAP)�� 18
3.3 Osteotomy- and Corticotomy-Assisted Tooth
Movement �� 18
3.4 Surgery-First Orthognathic Approach’s Molecular Response�� 19
References�� 20
vii
viii Contents
4 Biomechanical Principles of Surgery-First Orthognathic Approach�� 23

4.2 Six Degrees of Freedom (6DoF)�� 23
4.2.1 Natural Head Position: 2D and 3D �� 24
4.3 Considerations of Translational (Sagittal, Transverse, Vertical)
and Rotational Envelopes (Pitch, Roll, and Yaw) �� 25
4.3.1 Virtual Surgical Planning�� 28
References�� 34
5 Surgery-First Orthognathic Approach Treatment Protocol:
Orthodontic Considerations�� 37
5.2 Pre-surgical Orthodontics �� 37
5.2.1 Orthodontic Appliances (Brackets and Arch Ligation)�� 38
5.3 Pre-surgical Preparation�� 44
5.3.1 Determination of Transitional Occlusion�� 44
5.3.2 Surgical Splint Fabrication, Intermaxillary Fixation�� 47
5.4 Post-surgery in Surgery-First Orthognathic Approach �� 48
5.4.1 Post-surgical Orthodontic Considerations�� 48
5.4.2 Post-surgical Orthopaedic Management, i.e. Chin
Cup Therapy�� 48
References�� 50
6 Surgical Management: Author’s Surgery-First Treatment Protocol�� 51
6.2 Type of Surgery with Indications, Complications,
Considerations and Stability with the Type of Surgery�� 52
References�� 54
7 Management of Skeletal Class I Malocclusion with
Surgery-First Orthognathic Approach�� 55
7.2 Skeletal Class I Malocclusion SFOA Treatment Guidelines�� 55
7.3 Case Report�� 57
7.3.1 Treatment Objectives�� 57
7.3.2 Surgical Plan �� 57
7.3.3 Treatment Progress �� 58
8 Management of Skeletal Class II Malocclusion with
8.2 Treatment of Various Skeletal Class II Cases �� 66
Contents ix
9 Management of Skeletal Class III Malocclusion with

9.2 SFOA Treatment Guidelines in Three Dimensions
Based on the Degree of Complexity �� 83
9.3 Case Presentation�� 83
9.3.1 Treatment�� 84
10 Management of Skeletal Asymmetry with Surgery-First
10.2 Case 1: A Maxillary Occlusal Cant Extending Anteriorly to
Posteriorly: Its Influence on MMC and on Subsequent
Treatment Planning �� 108
10.3 Case 2: Differential Anterior and Posterior Region
Maxillary Occlusal Cant: Its Influence on MMC and on
Subsequent Treatment Planning�� 112
References�� 123
11 Pre- and Post-surgery Patient Care Checklist and
Patient Instruction �� 125
11.2 Pre- and Post-surgery Checklist: Category, Conditions,
Assessment Tools, and Management Plan�� 125
11.2.1 Systemic Conditions, Medication/Anaesthesia Clearance��128
11.2.2 Psychological Assessment�� 128
11.2.3 Mental/Cognitive Assessment �� 129
11.2.4 Social Support �� 129
11.2.5 Postoperative Nutrition (Fluid and Electrolyte Balance)�� 130
11.2.6 Patient’s Informed Consent �� 130
11.2.7 Postoperative Pain Management �� 130
11.2.8 Oral Prophylaxis Requirements/Guidance�� 131
11.2.9 Orthodontic and Jaw Surgery�� 131
11.3 Instructions for Patients and Care Givers: Dos and Don’ts�� 131
12 Potential Complications and Management of SFOA�� 135
12.2 Orthodontist-Related Complications and Management�� 135
12.2.1 Pre-surgery Phase�� 135
12.2.2 Surgery Phase�� 137
12.2.3 Post-surgery Phase�� 140
12.3 Surgery-Related Complications and Management �� 140
x Contents
13 Outcome Assessment of Surgery-First Orthognathic Approach �� 145

13.2 Treatment Duration of SFOA Versus Conventional Orthognathic�� 145
13.2.1 Orthodontic Treatment Difficulty Level: Minimal
to Moderate �� 154
13.2.2 Orthodontic Treatment Difficulty Level: Severe�� 154
13.3 Stability of SFOA Versus Conventional Jaw Surgery �� 155
13.4 Quality of Life Outcomes and Psychological Status for SFOA�� 155
13.5 SFOA: Evidence-Based Practice�� 156
14 Future of Surgery-First Orthognathic Approach �� 161
14.2 3D Image Acquisition and Diagnosis �� 161
14.3 Virtual Surgical Planning (VSP) �� 167
14.4 ‘Tools of Transfer’ for Surgery Planning�� 169
14.4.1 CAD/CAM Splints with Extra-Oral Bone-Borne
Support (EOBS)�� 169
14.5 3D Printing/Rapid Prototyping in Surgery �� 170
14.6 Augmented Real-Time and Virtual Surgical Navigation�� 170
Introduction to Surgery-First
Orthognathic Approach (SFOA) 1
We are not makers of history. We are made by history.

—Martin Luther King, Jr.
1.1 Introduction
Surgery-first orthognathic approach is an emerging science whose roots can be

traced back to the 1960s. An overview of surgery-first orthognathic approach shows
the evolution of SFOA. ‘Jaw surgery’ pioneers and predecessors thought process
and ideas are what shaped surgery-first orthognathic approach (SFOA). What was
their approach, and what made the technique catch the attention of the ‘practitioners
of the day’ and subsequently descended into oblivion for a considerable period of
time? SFOA found a revival itself from a profound relying on ‘heuristic judgement’
of the early resurrection days to a more concrete epistemological method in the light
of modern time’s evolved armamentarium and evidence.
1.2 verview of Surgery-First Orthognathic

O
Approach (SFOA)
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].
© Springer Nature Switzerland AG 2019 1

C. K. Chng et al., Surgery-First Orthodontic Management,
https://doi.org/10.1007/978-3-030-18696-8_1
2 1 Introduction to Surgery-First Orthognathic Approach (SFOA)
Pre-surgical orthodontics and surgery-related orthodontics, in general, were not

deemed important components on the overall management of the ortho-orthogna-
thic patient. Jaw surgery was performed either before orthodontic treatment or after
the removal of orthodontic appliances [5]. Jaw surgery was carried out without pre-
surgical orthodontics (Fig. 1.1), which unwittingly gave rise to surgery-first
approach. Given the circumstances and several factors as enumerated below, the
authors cogitate that the following factors were some of the reasons that discour-
aged orthodontists and oral surgeons to work in tandem as far as jaw surgery cases
were involved.
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
Fig. 1.1 Surgery-first orthognathic approach timeline

1960 1970-2000 2000-2010 2011-Present
1.2 Overview of Surgery-First Orthognathic Approach (SFOA)
2009 Nagasaka et al Significant reduction of treatment time.

2010 Sugawara et al Recommended orthodontics just before
surgery
2010 Villegas et al Facial asymmetry cases were treated
with SFOA
2010 Wang et al Transverse dental corrections do not
require pre-surgical orthodontics
2010 Kao et al SFOA Skeletal stability was comparable
to conventional surgery
3
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:
• On a technique front: Pre-surgical orthodontics to eliminate dental compensation

became more refined. The development of better rigid internal fixation tech-
niques with same-day surgery shortened treatment phases and improved stability
of postsurgical position.
• On a technological front: State-of-the-art navigation systems coupled with
computer- aided designed/computer-aided manufactured splints for surgical
transfer of virtual jaw planning made ‘surgical orthodontics’ more precise and
accurate.
• On a communication and education front: Many dental conferences are now
organized with dedicated jaw surgery session. Dental schools have included
jaw surgery curriculum for both orthodontic and surgery students with joint
clinics in specialty-based hospitals. Where such facilities are unavailable,
novel ways of education includes teleconferencing for combined clinics for
residents. Didactics in these schools emphasises the value of multidisciplinary
team-based approach with patient-centric treatment plan and comprehensive
management.
1.3 Revival of Surgery-First Orthognathic Approach
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.
1. Pre-surgical orthodontics is a prerequisite for conventional jaw surgery for arch

coordination and overcomes dental compensation to reveal true extent of skeletal
deformity.
2. Pre-surgical orthodontics would take a considerably long period of time (12–18
months) which is a significant drawback for patients.
3. There is a worsening of facial profile before surgery which could cause negative
impact on the perception of patients’ quality of life.
Following the commentary of Dr William Bell that conventional jaw surgery is

‘too complicated, too invasive, too-time consuming, and too unpredictable’, a para-
digm shift would be necessary to ensure jaw surgery to become more efficient,
affordable, predictable, and convenient with a focus on utilizing advanced three-
dimensional imaging technology and empirical evidence to mitigate the effects of
pre-surgical orthodontic treatment.
SFOA has been around for more than four decades, but the emphasis was spo-
radic in approach, until Lee et al., in 1994 [15], showed that early correction of
skeletal and soft tissue deformities would make correction of misaligned teeth eas-
ier by establishing a relatively normal (Class I) skeletal and soft tissue environment
post-surgically. However, the benefits of SFOA, as described by Lee et al., did not
1.4 Comparison of Conventional and Surgery-First Orthognathic Approach 5
accompany substantial clinical evidence to prove the claims. Subsequently, nearly

after a decade since Lee et al.’s publication, SFOA regained interest when Nagasaka
et al. performed SFOA in a Class III individual. Consequently various groups, espe-
cially in the Asia-Pacific region, published case series, prospective studies, system-
atic reviews, and meta-analysis in the past years which have led to a new paradigm
shift in the treatment approach as far as treating jaw deformities are concerned.
1.4 omparison of Conventional and Surgery-First

C
Orthognathic Approach (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
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
Diagnosis is not the end, but the beginning of practice.

—Martin H. Fischer (1879–1962)
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.
2.2 rthodontic and Surgical Considerations: Case

O
Selection and Guidelines
Surgery-first orthognathic approach (SFOA) is fast becoming an accepted modality

as part of jaw surgery and involves meticulous treatment planning and execution.
Orthodontists play a pivotal role from the beginning and, together with the surgeon,
perform patient evaluation and data collection (photographs, study models, and
radiographs). Further, they perform the ‘mock surgery’ either by conventional
method (paper surgery and model surgery) or 3D-assisted method (3D composite
modelling and stereolithography) to facilitate the fabrication of a surgical bite splint.
The surgical bite splint will guide the surgeon to execute the surgery as planned
based on the earlier surgical planning. Figure 2.1 explains the routine workflow of
SFOA.

https://doi.org/10.1007/978-3-030-18696-8_2
8 2 Diagnosis and Treatment Planning of Surgery-First Orthognathic Approach
SFOA: Diagnosis and treatment planning
Data Gathering
Envelope of Discrepancy
Pre-surgical Jaw Distraction

Orthodontics alone
Assessment Surgery Osteogenesis
Transitional
occlusion
Mild or no ortho
Case selection criteria Moderate to severe
treatment
Sagittal Vertical Transverse
Dental Skeletal
consideration consideration
Treatment plan
Extraction Non-extraction Single Jaw Double Jaw
Fig. 2.1 Routine workflow of surgery-first orthognathic approach
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:
• In sagittal plane—mild proclination or retroclination of teeth

• In transverse plane—minimal posterior crossbite or absence of a collapsed bite
• In the vertical plane—mild curve of Spee with no significant deep bite or open
bite
More complex cases can be undertaken by an experienced practitioner for

SFOA. Several factors are to be taken into consideration, such as:
• Pre-surgical complexities (skeletal, dental, and soft tissue)

• Orthodontic treatment mechanics (pre- and post-surgical)
• Transitional occlusion
2.2 Orthodontic and Surgical Considerations: Case Selection and Guidelines 9
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:
• Orthodontic-driven (see Sect. 2.2.1)

• Surgery-driven (see Sect. 2.2.2)
All four first premolar

extraction +
Skeletal protusion + Bimaxillary set-back Jaw
dental proclination surgery, maxillary anterior Set-up occlusion in
Class I segmental osteotomy Class I molar relation Consider genioplasty for
Bimaxillary + chin augmentation
proclination Non-extraction Positive overjet
Skeletal protrusion + +
No dental proclination Bimaxillary set-back
Jaw surgery
Protruded maxilla + Le Fort I set-back or

normal mandible Upper first premolar Set-up occlusion in consider creation of
Sagittal Class II extraction + maxillary anterior Class I molar relation large positive overjet for
segmental osteotomy Or Class II in cases of correction of retrcolined
upper first premolar lower incisors
Protuded maxilla + Le Fort set-back+ extraction
Retruded mandible BSSO advancment
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
Lower first premolar Set-up occlusion in

severe extraction + Class III relationship Align lower incisors
retroclined and anterior + utilizing the large overjet
crowded lower incisors segmental osteotomy + BSSO large positive overjet
set-back,
To correct crossbite
Skeletal cross bite ≤
postoperatively
molar width
Cross bite
Set-up occlusion Consider using TPA

SFOA Skeletal cross bite > 3-piece Le Fort I osteotomy
within the tooth to correct bite post-
Treatment transverse molar width of the maxilla.
movement envelope operatively
Guidelines
Skeletal scissor bite >

Scissors Bite Consider SARPE
molar width
Set-up occlusion
Edge-to-edge incisor
BSSO and establish
advancement posterior Intrude anterior
moderate to deep teeth and allow
Class II mandibular curve disocclusion
eruption of posterior
of Spee teeth
Lower anterior Set-up occlusion in
segmental intrusion Class I relationship
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
Anterior segmental lower incisors

moderate to deep Set-up occlusion in
osteotomy intruded + upper
mandibular curve Class I relationship
incisor extruded
of Spee
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
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].
2.2.3 One Patient Two Problem Concept
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.
2.3 onventional Jaw Surgery Planning: Paper Surgery

C
and Model Surgery
‘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
efficient planning and execution leading to the correction of maxilla-mandibular

complex deformity. The diagnostic information obtained from clinical findings and
radiographic assessments are integrated in the ‘paper surgery’ to establish a surgical
plan. Further, the ‘paper surgery’ is emulated on a face-bow transfer, articulator-
mounted study models in ‘model surgery’ for surgical splint creation. The treatment
plan, when using 2D data, is essentially a composite of clinical evaluation and ceph-
alometric (both lateral and postero-antero cephalograph) assessment using
Schwarz’s ‘gnathic profile field (GPF)’. GPF is a simple yet efficient clinical
appraisal of a patient’s maxillofacial profile pattern by observing patients in their
profile view. Also, ‘rule of thirds’ is applied for the evaluation and correction of
face. ‘Rule of thirds’ divides the face horizontally into thirds with reference lines
drawn at the hairline, eyebrows, base of nose, and chin (Fig. 2.3).
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
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].
Fig. 2.4 Schematic illustration of 2D-assisted SFOA planning

2.4 3D Virtual Surgical Planning and 3D Splint Fabrication 13
2.4 3D Virtual Surgical Planning and 3D Splint Fabrication
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
2.5 Conclusion
Strategic planning with emphasis on careful considerations such as requirements

and objectives of each case plays a critical role in the successful execution of a treat-
ment plan. The essential and supplementary tools of both analogue and 3D-assisted
planning and execution are discussed, and their importance is emphasized.
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
The skeleton is a record of past events and an oracle of future

behaviors.
—Webster S [1]
3.1 Introduction
Harold M. Frost, an American orthopaedic surgeon, first described regional

acceleratory phenomenon (RAP) as ‘a tissue reaction to different noxious stimuli’
[2]. Frost proposed the existence of RAP at a fracture site causes an acceleration of
the normal repair and renewal process in both hard and soft tissue brings about
healing within a period of time. This ubiquitous phenomenon plays a primary role
in the healing process of all tissues. Further, in order to better define the remodelling
process at the fracture site, Frost observed the existence of numerous remodelling
sites and referred them as basic multicellular units (BMUs).
3.2 Regional Acceleratory Phenomenon
The BMUs respond to various biomechanical stimuli and are characterized by

several distinctive phases, (a) activation phase, (b) resorption phase, (c) resting (or
reversal) phase, and (d) formation phase, which represent the events involved in the
bone healing process. The interaction of regional reparative reactions and the for-
mation of granulation tissue result in the repair of the damage structure to the state
of its original biomechanical integrity [3–5]. Since then, several independent
researchers have placed a great deal of attention to evaluate the bone physiology on
the basis of Frost’s RAP theory. This has given way to further our knowledge on the
rate of remodelling in the region of bone fracture and also in understanding how
tissue activity potentiates tissue healing under the influence of various local tissue

https://doi.org/10.1007/978-3-030-18696-8_3
16 3 Biological Principles and Responses to Surgery-First Orthognathic Approach
Corticosteroids, Osteocalcin
Amino acids, Cytokines,

Genes, Race, Age, Sex
Parathyroid, Hormone,
Calcium, Vitamin D3,
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
pressure, increased GCF activity

Substance P, CGRP, Histamine,
disturbance, increased tissue

Teeth (Pulp) and periodontal
Circumferential vascular
Bradykinin, IL-1 α,4
ligament
Reactive Oxygen Species (ROS)
Platelet activating factors (PAF)
Arachidonic acid metabolites
Lysosomal component
nitrogen oxide (NO)

Vasoactive amines
inflammatory process
Neuropeptide
Cell derived
Cytokines
Non-infection
Surgery intervention
Rapid Wallerian degeneration

Neurotrophic factors release,
Pain, Axonal degeneration
Schwan cell activation
catecholamine release
PG, NGF, SP, HIF-1α
Nervous system
TNFR1,R2
TLR1-9
IL-1R1
Chemical Mediators
Infection
RAP
Bleeding, Inflammation, chemotaxis,
Angiogenesis, Neovascularisation,
Perfusion, Proliferation,
VEGF, C3a,b; C5a,b
fibrosis, cell turnover

LT-B4,C4,D4,E4
Soft tissue
Mac-1,NO
PG-D,E,F
Complement activation C3a,b,5a,b
Injury
Fibrinolysis system
Plasma derived
Clotting system
Fractures
Kinin System
Resorption, formation, osteoblast

maturation, BMU, mIcrodamage
PGE2, RANKL, Cbfa1/Runx2
IFN, bALP, BMP, DKK
IL-1 a,OPG,PDGF
TNF, ICTP, OSM
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
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’.
3.2.1 Systemic Acceleratory Phenomenon (SAP)
Mueller, Schilling, and team at the University of Heidelberg, Germany, conducted a

series of experiments to show that restoration of a local defect in a rat model not
only leads to a regional acceleratory phenomenon (RAP) but also to a systemic
acceleratory phenomenon (SAP) at distant sites of the skeleton [6–8]. SAP leads to
the release of osteogenic growth peptide (OGP) which stimulates proliferation of
alkaline phosphatase activity that ultimately accelerates bone repair process.
3.3 steotomy- and Corticotomy-Assisted Tooth Movement

O
(Table 3.1)
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
significantly influences tooth movement [9–13]. Corticotomy is thought to induce a

regional acceleratory phenomenon (RAP) that amplifies ‘ARF sequence’ in osteope-
nic bone [11, 14].
Longitudinal studies using computerized tomograms have shown that osteotomy
and alveolar corticotomy produce different bone responses. Wang et al. histologi-
cally assessed in rats how dentoalveolar surgery alters the biology of tooth move-
ment and showed that corticotomy site induced RAP with increased bone
demineralization around the dental root allowing for movement through the demin-
eralized bone prior to remineralization, whereas distraction osteogenesis occurs at
the osteotomized segment [15]. Nonetheless, both processes form an integral part of
bone repair [16]. Teng and Liou showed, in beagle dogs, that interdental osteoto-
mies induce RAP and significantly accelerate orthodontic tooth movement by
assessing rate of tooth movement, bone-specific biomarkers in gingival crevicular
fluid, and bone demineralization by cone beam computed tomography scans (alveo-
lar bone grey scale) [17].
3.4 urgery-First Orthognathic Approach’s

S
Molecular Response
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
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
RAP is a complex physiologic phenomenon that researchers have only begun to

understand. Further effort needs to be carried out in order to better understand the
phenomenon. Several areas of RAP need further attention so that its clinical impli-
cations can be fully understood. Some areas of potential research would be:
• Investigation of how chemical mediators (complement, vasoactive amines,

neuropeptide, cytokines, vascular endothelial growth factor, etc.) are influenced
by various noxious stimuli.
• Further evaluation of molecular mechanisms underlying accelerated orthodontic
tooth movement and effects on bone, soft tissues, nervous system, and
periodontium.
• In-depth analysis of RAP side-effects and risks associated with correlation of
bone strength, fragility, and long-term characteristic evaluation of skeletal
maturation.
• Estimation of targeted changes in expression of specific genes.
References
1. Webster S. The past, present, and future of bone morphometry: its contribution to an improved
understanding of bone biology. J Bone Miner Metab. 2005;23:1–10.
2. Frost H. The regional acceleratory phenomenon: a review. Henry Ford. Hosp Med J. 1983;31:3.
3. Verna C. Regional acceleratory phenomenon. Tooth movement, vol. 18. Basel: Karger
Publishers; 2016. p. 28–35.
4. Frost HM. Tetracycline-based histological analysis of bone remodeling. New York: Springer;
1969.
5. Frost HM. Defining osteopenias and osteoporoses: another view (with insights from a new
paradigm). Bone. 1997;20:385–91.
6. Mueller M, Schilling T, Minne HW, Ziegler R. A systemic acceleratory phenomenon (SAP)
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.
9. Fischer T. Orthodontic treatment acceleration with corticotomy-assisted exposure of palatally
impacted canines: a preliminary study. Angle Orthod. 2007;77:417–20.
References 21
10. Liou EJ, Huang CS. Rapid canine retraction through distraction of the periodontal ligament.
Am J Orthod Dentofacial Orthop. 1998;114:372–82.
11. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following
mucoperiosteal flap surgery. J Periodontol. 1994;65:79–83.
12. Lee W, Karapetyan G, Moats R, Yamashita D-D, Moon H-B, Ferguson D, et al. Corticotomy-/
osteotomy-assisted tooth movement microCTs differ. J Dent Res. 2008;87:861–7.
13. Wilcko WM, Wilcko MT, Bouquot J, Ferguson DJ. Rapid orthodontics with alveolar reshaping:
two case reports of decrowding. Int J Periodontics Restorative Dent. 2001;21:9–20.
14. Bogoch E, Gschwend N, Rahn B, Moran E, Perren S. Healing of cancellous bone osteotomy
in rabbits—part I: regulation of bone volume and the regional acceleratory phenomenon in
normal bone. J Orthop Res. 1993;11:285–91.
15. Wang L, Lee W, D-l L, Y-p L, Yamashita D-D, Yen SL-K. Tisssue responses in corticotomy-
and osteotomy-assisted tooth movements in rats: histology and immunostaining. Am J Orthod
Dentofacial Orthop. 2009;136(770):e1–e11.
16. Yen SL. A comparison between osteotomy and corticotomy-assisted tooth movement. Tooth
movement, vol. 18. Basel: Karger Publishers; 2016. p. 124–9.
17. Teng GY, Liou EJ. Interdental osteotomies induce regional acceleratory phenomenon and
accelerate orthodontic tooth movement. J Oral Maxillofac Surg. 2014;72:19–29.
18. Buschang P, Campbell P, Ruso S. Accelerating tooth movement with corticotomies: is it
possible and desirable? Semin Orthod. 2012;18:286–94.
19. dos Santos-Pinto A, Araújo E, Ribeiro GLU, et al. An interview with Peter H. Buschang.
Dental Press J Orthod. 2014;19:23–36.
20. Zingler S, Hakim E, Finke D, Brunner M, Saure D, Hoffmann J, et al. Surgery-first approach
in orthognathic surgery: psychological and biological aspects—a prospective cohort study. J
Craniomaxillofac Surg. 2017;45:1293–301.
21. İşeri H, Kişnişci R, Bzizi N, Tüz H. Rapid canine retraction and orthodontic treatment with
dentoalveolar distraction osteogenesis. Am J Orthod Dentofacial Orthop. 2005;127:533–41.
22. Liem A, Hoogeveen E, Jansma J, Ren Y. Surgically facilitated experimental movement of
teeth: systematic review. Br J Oral Maxillofac Surg. 2015;53:491–506.
23. 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
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24. Patterson BM, Dalci O, Darendeliler MA, Papadopoulou AK. Corticotomies and orthodontic
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25. Vercellotti T, Podesta A. Orthodontic microsurgery: a new surgically guided technique for
dental movement. Int J Periodontics Restorative Dent. 2007;27(4):325–31.
26. Kişnişci RŞ, İşeri H, Tüz HH, Altug AT. Dentoalveolar distraction osteogenesis for rapid
orthodontic canine retraction. J Oral Maxillofac Surg. 2002;60:389–94.
27. Shoreibah E, Ibrahim S, Attia M, Diab M. Clinical and radiographic evaluation of bone grafting
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facilitated orthodontics. Case reports. J Periodontol. 1990;61:234–8.
29. Shoreibah E, Salama A, Attia M, Abu-Seida S. Corticotomy-facilitated orthodontics in adults
using a further modified technique. J Int Acad Periodontol. 2012;14:97–104.
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e1–8.
Biomechanical Principles of
Surgery-First Orthognathic Approach 4
Phileas Fogg, having shut the door of his house at half-past

eleven, and having put his right foot before his left five hundred
and seventy-five times, and his left foot before his right five
hundred and seventy-six times, reached the Reform Club.
—Jules Verne, Around the World in Eighty Days
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].
4.2 Six Degrees of Freedom (6DoF)
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).

https://doi.org/10.1007/978-3-030-18696-8_4
24 4 Biomechanical Principles of Surgery-First Orthognathic Approach
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)
4.2.1 Natural Head Position: 2D and 3D
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).
4.3 onsiderations of Translational (Sagittal, Transverse,

C
Vertical) and Rotational Envelopes (Pitch, Roll, and Yaw)
Traditional analogue techniques such as 2D radiography (lateral and postero-

anterior cephalographs), facial photographs, and dental casts could be used to plan
jaw surgery. Typically, translational and rotational movements of MMC are ascer-
tained by amalgamation of radiographs (lateral and PA cephalographs) and gnathic
profile field. The rule of thirds, along with pre-surgical measurements chart, is used
for the initial assessment of SFOA cases (see Chap. 2, Fig. 2.3).
Three horizontal planes and one vertical plane are drawn on the PA cephalograph
and two horizontal reference planes on the lateral cephalograph (Fig. 4.2). Horizontal
planes’ (PA cephalograph) topmost plane (cranial reference plane) runs from the
left greater wing superior orbit—intersection of superior border of greater wing of
sphenoid bone and lateral orbital margin, right and left. The middle plane (orbital
plane) runs from midpoint of inferior orbital margin, right and left. The bottom
plane (maxillary canine plane) runs from maxillary canine—tip of maxillary canine,
right and left [12]. The vertical plane (midsagittal plane) is a plane running from
crista galli (uppermost point on crista galli) to the line connecting cranial horizontal
plane or orbital plane. In SFOA planning, the maxillary canine plane is subjective
and may not be reliable as the teeth are not aligned, hence making maxillary canine
plane difficult to use; however, the authors suggest to ascertain the true extent of
maxillary teeth deviation by clinical evaluation (please refer to Chap. 2, Fig. 2.3).
Horizontal planes’ (lateral cephalograph) top line, Frankfort horizontal plane, runs
from 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 cephalostat (machine porion) to a point midway between the lowest point on
the inferior margin of the two orbits (orbitale). The bottom plane (maxillary plane)
runs from the anterior nasal spine (ANS), the most anterior point on the maxilla at
the nasal base, to the posterior nasal spine (PNS), the tip of the posterior nasal spine
of the palatine bone, at the junction of the soft and hard palate.
The maxillary template with maxillary plane (ANS-PNS) is one of the key ele-
ments for planning six degrees of freedom movements. Although infinite movements
are possible whilst correcting the maxillo-mandibular complex (MMC), however, the
authors recommend application of some important ‘pivotal points’ to correct the
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
Fig. 4.3 Various movements of maxilla as ascertained by 6DoF
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
as it allows the clinician to utilize the routine tools of assessment without depending
on supplementary 3D imaging modalities.
4.3.1 Virtual Surgical Planning
Advancements in computed tomography (CT) imaging and CAD/CAM (computer-

aided design and computer-aided manufacturing) have made the adoption of this
technology a lot easier and also the cost of adoption down in recent years. The plan-
ning of orthographic surgery using 3D technology is fast becoming the preferred
choice of orthodontists and surgeons. Once the CT image is oriented to NHP, SFOA
planning is primarily dependent on evaluating and setting the maxillary position.
Once the maxilla is positioned, taking into account 6DoF, the mandible is
essentially positioned based on the maxillary position whilst taking care of final
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
Fig. 4.4 (continued)
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
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).
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
Fig. 4.9 Immediate post-surgery extra- and intra-oral images
Fig. 4.10 Photos showing in between treatment
The maxilla is planned for differential impaction (LeFort I osteotomy) in 6DoF

movements as explained in Table 4.1.
Fig. 4.11 Post-treatment intra- and extra-oral images
Fig. 4.12 Post-treatment lateral cephalograph and OPG
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
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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References 35
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Surgery-First Orthognathic Approach
Treatment Protocol: Orthodontic 5
Considerations
The secret of getting ahead is getting started. The secret of

getting started is breaking your complex, overwhelming tasks
into small manageable tasks, and then starting on the first one.
—Mark Twain
5.1 Introduction
Orthodontic management involving bracket selection, arch wire sequencing,

surgical splint duration, and elastic use plays an important role in the success of
surgery-first orthognathic approach cases. Considerations during pre-, post-surgery,
and pre-surgical preparation phases must be taken into account to take full advantage
of RAP for the conversion of transitional occlusion into final occlusion. The aim of
this chapter is to describe the different treatment modalities adopted by various
authors and also to enumerate our approach.
5.2 Pre-surgical Orthodontics
The pre-surgical orthodontics phase in SFOA involves a much shorter duration as

opposed to conventional jaw surgery. In conventional jaw surgery, there is an
emphasis on (1) arch coordination (dental expansion of the arches), (2) alleviation
of crowding (levelling and alignment), and (3) dental decompensation in the form
of up righting retroclined teeth and retraction of proclined teeth. This is done to
ascertain the true skeletal deformity, [1] thus making it a time-consuming pre-
surgical orthodontic stage. In SFOA, the pre-surgical orthodontic stage is reduced to
minimal orthodontics where brackets are bonded but minimal or no orthodontic
tooth movement is carried out. The orthodontic tooth movement is carried out
post-surgery.

https://doi.org/10.1007/978-3-030-18696-8_5
38 5 Surgery-First Orthognathic Approach Treatment Protocol: Orthodontic…
5.2.1 Orthodontic Appliances (Brackets and Arch Ligation)
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
extrusion stabilization occlusion masticatory

of the function
mandibular
model
Baek et al. NR Bonded directly Passive surgical No, only rigid Splint Creation of 4 weeks Class III elastics NR
(2010) [3] to tooth surface wires, fixation removed large overjet for to prevent
or ligated to dimension NR after 4 weeks lower incisor relapse of the
brackets correction anterior crossbite
Liao et al. 1 month 0.022″ × 0.028″ 0.016″ × 0.022″ No, only rigid Splint Molars are the Immediately Class II elastics 0.016″ × 0.022″
(2010) [4] before NiTi, 1–3 days fixation with removed guide to after surgery for correction of Niti
surgery before surgery bone plates or immediately anteroposterior incomplete 0.016″ × 0.022″
brackets screws after surgery jaw positioning incisor SS
bonded decompensation
Villegas 1 week 0.022″ slot 0.016″ × 0.016″ No, rigid Used for Class III was 2 weeks Elastomeric 0.016″ × 0.016″
et al. before NiTi fixation with achieving overcorrected to chain and NiTi NiTi upper, 0.014″
(2010) [5] surgery additional 4 planned Class II coil springs used NiTi lower,
miniplates in post-surgical occlusion from miniplates 0.016″ × 0.016″
the occlusion SS after 2 weeks
infrazygomatic
crest and
mandible
(continued)
39
Table 5.1 (continued)
40
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 and Surgical Transitional commencement duration, and Arch wire
year time Brackets Wires purpose splints occlusion post-surgery purpose sequencing
Uribe et al. 4 weeks 0.022″ slot 0.016″ × 0.016″ IMF removed Splint used Occlusion was 2 weeks Short Class II Smaller dimension
(2013) [6] NiTi after surgery for maxillary planned based elastics wires
arch on corrective
expansion, skeletal needs
removed
6 weeks after
surgery
Hernandez- 1 week Soft arch wires 0.12-mm Used for 2 weeks Z elastics Change every
Alfaro before 1 day before interdental achieving provided 2–3 weeks
et al. surgery surgery wire loops and planned additional
(2014) [7] left in place for post-surgical transversal
2 weeks occlusion control
Aristizabal 1 week Self-ligating No arch wire 0.014″ NiTi NR 3/16″, 3.5 Oz • 0.014″
et al. wires placed 1/4″, 3.5 Oz • 0.014″ × 0.025″
(2015) [8] in the Cu NiTi
operation • 0.018″ × 0.025″Cu
room NiTi
• 0.019″ × 0.025″
TMA
5 Surgery-First Orthognathic Approach Treatment Protocol: Orthodontic…
Choi et al. NR Brackets IMF removed Used for ‘Surgical NR NR NR
(2015) [9] bonded after surgery simulating temporary
surgery and occlusion’ was
estimate the adapted into
extent of skeletal
post-surgical discrepancy and
orthodontic reorganized in
treatment the predicted
location
HB Yu No Brackets Passive SS NR Used for Intended 2 weeks NR NR
et al. pre-surgical bonded ligature wire simulating transitional
(2015) [10] orthodontics surgery occlusion

(ITM), molar
relation used as
a starting point
to guide a
temporary
occlusion
NR not reported, IMF intermaxillary fixation, SFOA surgery first orthognathic approach, SS stainless steel
41
42
Table 5.2 Authors SFOA—treatment protocols: pre-, during, and post-SFOA

Authors SFOA treatment protocols: pre-, during, and post-SFOA
Pre- Preoperative 1–2 weeks
SFOA orthodontic
Preparation time
Orthodontic appliance Brackets 0.022″ × 0.028″ slot
Wires Ligation with SS passive ligature wire, this approach has the following
advantages:
• No undue tooth movement before or during surgery as the wire is passive,
unlike active arch wires
• All brackets are secured with no possibility of dislodgment, even if the
brackets dislodge, the passive ligature will not allow the bracket to release and
accidental drop into open surgical sites
• No additional use of rubber ligature tie, hence avoidance of oral hygiene
deterioration due to rubber ties
• Avoidance of complex wire bending in order to adapt to malocclusion
• Saves chairside time
During Intermaxillary IMF used only to stabilize the jaws during surgery such that rigid fixation with bone plates or screws is used to fix the
SFOA fixation duration and osteotomy segments
purpose
Surgical splints Used for achieving planned post-surgical occlusion
• For single jaw surgery: only one splint is used
• For double jaw surgery: two splints are used (intermediate and final)
Use of splints is only during the time of surgery as a guide for the surgeon and removed post-surgery to commence tooth
movement
5 Surgery-First Orthognathic Approach Treatment Protocol: Orthodontic…
Authors SFOA treatment protocols: pre-, during, and post-SFOA
Post- Transitional occlusion An occlusion is created such that orthodontically treatable malocclusion persists. (See chapter text for further
SFOA understanding.)
Orthodontic treatment 1–2 weeks
commencement
post-surgery
Type of elastics, Wires Elasticsa
duration, and purpose Class II/Class III Midline correction Anterior box Posterior box
0.018″ Quail Fox Parrot Fox
Cu NiTi/0.016″ × 0.022″ NiTi 3/16″(2 Oz/60 g) 1/4″(3.5 Oz/100 g) 5/16″ 1/4″(3.5 Oz/100 g)
Rabbit (2 Oz/60 g) Rabbit
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
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
0.21″ × 0.25″ TMA low friction/SS
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
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
5.3 Pre-surgical Preparation
1 . Determination of transitional occlusion.

2. Surgical splint fabrication, intermaxillary fixation.
5.3.1 Determination of Transitional Occlusion
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
be transfigured into a final occlusion to establish a stable relationship between the

occlusion and corrected skeletal structures. There is an ideal anatomic relationship
with opposing dentition exhibiting a cusp to fossa relationship which results in
structural durability, functional efficiency, and aesthetic harmony.
5.3.1.1 Prerequisites of a Transitional Occlusion

In the conventional orthognathic surgery approach, pre-surgical orthodontic
treatment is performed such that the dental component is decompensated to reveal
the true skeletal discrepancy. The pre-surgical orthodontics ensures fabrication of a
‘surgical splint’ such that the maxilla and mandible are placed in a ‘concrete occlu-
sion’ with minimal post-surgical orthodontic treatment. In SFOA, as teeth are mal-
positioned and lack proper occlusal antagonists in opposite arch, a ‘transitional
occlusion’ has to be set up post-surgically. Some key elements are enumerated in
this chapter (further details regarding case-by-case requisites of ‘transitional occlu-
sion’ are explained in Chaps. 7–10) before setting up a ‘transitional occlusion’ dur-
ing model surgery, and they are as follows:
• 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].
5.3.2 Surgical Splint Fabrication, Intermaxillary Fixation
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
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.
5.3.2.1 Surgical Splints Duration and Purpose

The primary purpose of the surgical splints is to emulate the planned surgical
movement (Fig. 5.5). Once the osteotomy cuts are made and the jaws are placed in
the planned position, the final surgical splint is discontinued without any further
use. Literature has indicated the use of the final surgical splint as a ‘post-surgical
occlusal guide’ with the intention that the surgical splint will minimize the occlusal
instability that may occur during the bone healing period. Also, if the surgical splint
is used as a post-surgical guide, the splint requires frequent selective grinding to
accommodate tooth movement [2, 3]. The surgical splint as a post-surgical occlusal
guide may not be necessary because:
1 . Rigid fixations can overcome the instability that might follow.

2. Occlusal guide grinding demands precision and considerable chairside time.
3. Minimal mouth opening, during the postoperative recovery time, the patient will
be under remarkable stress during the surgical splint manoeuvring.
5.4 Post-surgery in Surgery-First Orthognathic Approach
1 . Post-surgical orthodontic considerations.

2. Post-surgical orthopaedic management, i.e. chin cup therapy.
5.4.1 Post-surgical Orthodontic Considerations
Post-surgical orthodontic treatment, type of elastic, duration, and arch wire

sequencing are explained in further chapters and summarized in Table 5.2.
5.4.2 P
ost-surgical Orthopaedic Management, i.e. Chin Cup
Therapy
Post-surgery application of orthopaedic-force chin cup appliance in Class III

patients provides a substantial support for the retention of Class III correction, thus
5.5 Conclusion 49
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
ensuring minimal or no skeletal relapse. It is important to apply the chin cup

(Fig. 5.6) as early as possible, preferably, within the first week post-surgery whilst
taking care of facial swelling that has occurred after surgery. The chin cup should be
continued for the first 3–4 months post-surgery. Appropriate cushioning has to be
provided for patient comfort. The wear duration, direction, and force magnitude
play an important role when utilizing chin cup for the skeletal Class III correction
retention.
1. Wear duration: Apply as soon as possible postoperatively with full-time

application in the first month followed by nighttime (10–12 h) wear in the second
and third months.
2. Force magnitude: Broadly based on chin cup direction. The chin cup can be
divided into occipital-pull, intended for patients that had shown mandibular
protrusion with horizontal growth pattern (low-angle case), and a vertical-pull
(temporal pull), which could be used for steep mandibular plane angle and
excessive anterior facial height with vertical growth pattern (high-angle case)
(Fig. 5.6). Force magnitude, begin with lighter force of approximately 250 g
(9 Oz) per side and gradually increase to 16 Oz (450 g).
5.5 Conclusion
Considerations must be given to appropriate choice of orthodontic appliances. The

chapter describes the various options that are available and the reason for opting
them. Also, considerations during the contemplation of transitional occlusion are
described. Post-surgical orthodontic treatment strategies in terms of elastic usage,
duration, and arch wire sequencing are elaborated in detail with the application of
adjunct appliances such as chin cup.
Acknowledgement The authors would like to thank Prof. Akshai Shetty, Department of
Orthodontics, RV Dental College, Bengaluru, Karnataka, India, for providing Fig. 5.1.
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.
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:
1. A thorough understanding of the postoperative occlusal/interarch relationship of

maxillo-mandibular complex should be ascertained during the surgery planning
phase with emphasis on ‘transitional occlusion’, as the surgery relies minimally
on a stable occlusal relationship post-surgery.
2. While considering segmental osteotomies for the correction of skeletal jaw
deformity, the following anatomical structures demand special attention:
(a) Dentoalveolar structures.
• Tooth root (dimension, number, anatomical variations—dilaceration)
should be taken into account along with mechanical or iatrogenic damage
to the tooth root and subsequent pulpal necrosis.
• Periodontal ligament space (proximity to osteotomy cut) and alveolar
bone (fenestration, dehiscence, bone quality).
(b) Vascular supply (preservation of blood supply and haemorrhage).
(c) Neurosensory involvement (hyperaesthesia).
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,

https://doi.org/10.1007/978-3-030-18696-8_6
52 6 Surgical Management: Author’s Surgery-First Treatment Protocol
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].
6.2 ype of Surgery with Indications, Complications,

T
Considerations and Stability with the Type of Surgery
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
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
Skeletal Class I patients requiring surgery predominantly exhibit a severe sagittal

discrepancy, either in a bimaxillary protrusion or a retrusion relationship. Fig 7.1
describes the treatment guideline for the correction of such deformities. Control of
maxillary occlusal plane is the key for the successful treatment of skeletal Class I
malocclusion. This could be achieved either by en bloc distalization or mesializa-
tion of the maxilla by performing a LeFort I osteotomy and bilateral sagittal split
osteotomy or by anterior segmental osteotomy.
7.2 keletal Class I Malocclusion SFOA Treatment

S
Guidelines
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.

https://doi.org/10.1007/978-3-030-18696-8_7
56
All four first premolar

extaction +
Skeletal protrusion + Bimaxillary set-back Jaw
dental proclination surgery, maxillary anterior Maintain Class I
Class I segmental osteotomy moral relation
Conside genioplasty for
Bimaxillary +
chin corection
proclination Non-extraction Positive overjet
Skeletal protrusion + +
No dental proclination Bimaxillary set-back Jaw
surgery
Class I
SFOA
Treatment
Guidelines
Upright retroclined teeth +

Skeletal retrusion + Bimaxillary advancement
dental retroclination Jaw surgery Maintain Class I
Class I
molar relation Conside genioplasty for
Bimaxillary
+ chin augmentation
retroclination Non-extraction Positive overjet
+
Skeletal retrusion +
Bimaxillary advancement
No dental retroclination
Jaw surgery
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
7.3 Case Report
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).
7.3.1 Treatment Objectives
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.
7.3.2 Surgical Plan
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
Fig. 7.2 Pre-treatment extra-oral images

58 7 Management of Skeletal Class I Malocclusion with Surgery-First Orthognathic…
Fig. 7.3 Pre-treatment intra-oral images
Fig. 7.4 Pre-treatment CBCT images confirming the clinical observations
the advancement of the mandible, was planned, along with a reduction genioplasty
for the correction of the prominent chin.
7.3.3 Treatment Progress
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
8.1 Introduction
Figure 8.1 explains the Class II skeletal deformity characterization in three-

dimensional space and an effective surgical management plan to obtain stable
aesthetic and functional results. Several surgical strategies could be employed for
the resolution of skeletal Class II malocclusion, such as mandibular advancement,
maxillary differential impaction, or a combination to produce a counterclockwise
rotation of the maxillo-mandibular complex. In order to determine the suitability
of appropriate treatment planning, it is essential to ascertain the type of skeletal
Class II malocclusion and distinguish whether the skeletal Class II pattern arose
from a single entity such as maxilla or mandible or a combination of both. One
must also consider if there is a dental component contributing to the overall Class
II problem. Three cases have been described in this chapter that each required
their own individual different surgical plan. Various treatment options are
described in Figs. 8.2, 8.3, and 8.4. Case 1 is a ‘retreatment case’ comprising of
bimaxillary protrusion with severe chin retrusion that required MMC counter-
clockwise rotation. Case 2 is a severe skeletal Class II with deep curve of Spee
and low mandibular plane angle which was corrected by mandibular advancement
to create edge-to-edge bite and a counterclockwise rotation of the MMC. Case 3
is a Class II division 1 malocclusion having facial asymmetry, with buccal cross-
bite, heavily restored upper and lower posterior teeth, and was surgically treated
with a three-piece LeFort I osteotomy and mandibular advancement. Temporary
anchorage device was placed for the protraction of the second molar in the first
molar extraction space.

https://doi.org/10.1007/978-3-030-18696-8_8
64
Protruded maxilla + Le Fort I set-back or

normal mandible Upper first premolar
Set-up occlusion in consider creation of
extraction + maxillary anterior
Class I molar relation large positive overjet for
segmental osteotomy
Or Class II in cases of correction of retrcolined
Sagittal upper first premolar lower incisors
Protuded maxilla + Le Fort set-back+ extraction
Retruded mandible BSSO advancement
Skeletal cross bite ≤ postoperatively
molar width
Cross bite
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
Skeletal scissor bite > Consider SARPE

Scissors Bite
molar width
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
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
8.2 Treatment of Various Skeletal Class II Cases
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. 8.5 Pre-treatment extra- and intra-oral images
Fig. 8.6 Two-jaw surgery with counterclockwise rotation of MMC was planned. Refer text for
further explanation
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).
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
Fig. 8.9 Post-treatment extra- and intra-oral images

Fig. 8.10 Pre-treatment intra- and extra-oral images
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
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
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
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
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
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
Fig. 8.18 Images showing 1-week post-surgery showing fulfilment of objectives

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
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

8.3 Conclusion 81
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
Skeletal Class II problems can be treated predictably with surgery-first approach.

Moderate to severe cases requiring surgery necessitate meticulous evaluation of the
facial complex. In order to formulate an effective treatment plan, the following three
domains must be considered:
1. Dental considerations: Teeth positioning or repositioning plays an important role

when considering a surgical plan. Case 1 is a retreatment case which has teeth
previously extracted and the discrepancy has not been resolved. In this case,
further extraction is not viable but may lead to detrimental effects. A surgery was
planned to solve the skeletal issue that a camouflage orthodontic treatment plan
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
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.
9.2 FOA Treatment Guidelines in Three Dimensions Based

S
on the Degree of Complexity
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.
9.3 Case Presentation
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

https://doi.org/10.1007/978-3-030-18696-8_9
84 9 Management of Skeletal Class III Malocclusion with Surgery-First Orthognathic…
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
SFOA comprises of only one active orthodontic phase (post-surgical orthodontic

phase), as compared to conventional orthognathic surgery’s two phases of active
orthodontic treatment (pre-surgical orthodontic treatment for decompensation, lev-
elling and aligning, etc. and post-surgical orthodontic treatment). The pre-surgical
orthodontic phase for SFOA which essentially is a non-active or at least a minimally
active orthodontic phase is included for discussion for completeness.
• Phase I: Pre-surgical orthodontics.

• Phase II: Surgical phase.
• Phase III: Post-surgical orthodontics.
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
Lower first premolar Set-up occlusion in Align lower incisors

severe
extraction + Class III relationship Utilizibg the large
retroclined and
anterior + overjet
crowded lower incisors
segmental osteoery + BSSO large positive overjet
setback
Skeletal cross bite ≤ postoperatively
molar width
Cross bite
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
Skeletal scissor bite > Consider SARPE

Scissors Bite
molar width
Moderate to deep Set-up occlusion in Lower incisers

Anterior segmental inruded + upper
mandibular curve Class I relationship
osteotony incisor extruded
of Spee
Vertical
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
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)
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
Fig. 9.5 The final 3D prediction showing improved facial features along with establishment of
orthodontically manageable malocclusion
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
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
Fig. 9.8 Images showing intermediate and final surgical wafers

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
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
Fig. 9.13 Post-treatment CBCT images showing orthognathic skeletal relationship with normal
occlusion
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
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
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
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
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
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
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
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
Before Surgery Before Surgery
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
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
There is no symmetry in nature. One eye is never exactly the

same as the other.
—Edouard Manet
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

https://doi.org/10.1007/978-3-030-18696-8_10
108 10 Management of Skeletal Asymmetry with Surgery-First Orthognathic Approach
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]:
1. Landmark-based asymmetry assessment using specific landmarks such as

nasion, anterior nasal spine, and basion.
2. Model mirroring in midsagittal plane, in which the unaffected or the symmetri-
cal side is superimposed or overlaid on the asymmetrical side using fully auto-
mated, voxel-wise rigid registration of the cranial base and, subsequently, the
actual discrepancy computed.
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
asymmetry exists in both the vertical and anteroposterior planes. Surgery-first

approach was planned for the correction of maxillo-mandibular complex, and the
plan was simulated using face-bow transferred study models mounted on a semiad-
justable articulator (Fig. 10.3).
Treatment progress: All teeth were bonded, and 0.014″ Sentalloy wires were
placed in the upper and lower arches. Patient proceeded with surgery as planned.
One-week post-surgical extra-oral images and CBCT images showed fulfilment of
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.
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
A 19-year-old male reported to the orthodontic clinic with a chief complaint of

twisted jaw and difficulty in eating. On examination, CBCT scan and extra-oral
images showed severe Class III profile with maxillary hypoplasia, mandible exhibit-
ing left-sided deviation, and no temporomandibular joint abnormality (Fig. 10.9).
Intra-oral images revealed Class III molar with Class III canine relation on the
right side and Class II molar and canine relation on the left side with positive overjet
on the right and a reverse overjet on the left. She showed a moderate upper incisor
proclination and a moderate upper and lower crowding with an acute nasolabial
angle (Fig. 10.9).
Using CBCT images for evaluation of the occlusal canting, the anterior occlusal
aspect showed canting and was parallel to the FHP. The posterior occlusal aspect
showed a positive roll with the left side raised and the right side lowered. The skew-
ing of the mandible was partly influenced by the roll rotation of the maxilla and was
10.3 Case 2: Differential Anterior and Posterior Region Maxillary Occlusal Cant: Its… 113
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).
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

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
Fig. 10.9 Pre-treatment intra- and extra-oral photos with CBCT images
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
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
Fig. 10.13 One-month post-surgery showing improvement of mandibular asymmetry

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
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
Successful management of facial asymmetry with surgery-first orthognathic

approach depends on thorough evaluation of the asymmetry, in terms of skeletal and
dental patterns, and its influence on the maxillo-mandibular complex. The occlusal
canting and its cause must be ascertained with regard to the influence on the MMC
in three-dimensional space.
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
Checklists seem to provide a protection against such failures.

They remind us of the minimum necessary steps and make them
explicit. They not only offer the possibility of verification, but
also instill a kind of discipline of higher performance.
—Atul Gawande, The Checklist Manifesto
11.1 Introduction
In order for SFOA to result in a successful patient-centred outcome, it is of para-

mount importance that all stages of the process must be carefully planned and con-
sidered. The pre-surgical and post-surgical management can be made efficient by
employing checklists to ensure no steps are missed. Checklists also serve as an
adjunctive assessment tool that can assist in the evaluation of the case complexity at
the examination and diagnosis stage.
The success of SFOA is also dependent on the participation of the patient and
care giver. This is very much like orthodontic treatment. The dos and don’ts before
and after surgery need to be adequately conveyed. Only then can we minimize or
even eliminate unwanted sequelae and ensure the success of SFOA.
11.2 P
re- and Post-surgery Checklist: Category, Conditions,
Assessment Tools, and Management Plan
Adequate pre-surgery and post-surgery patient care comprises of (1) anticipatory

evaluation of impending conditions that may compromise the surgical outcome,
(2) use of the possible tools of assessment to rule out the conditions, and (3) and
execution of an effective management plan in order to curtail the conditions.

https://doi.org/10.1007/978-3-030-18696-8_11
Table 11.1 Pre- and post-surgery patient care checklist with category, conditions, assessment tools, and management plan
126
Category Conditions Assessment tools Management plan

Pre-surgery Systemic • Cardiovascular conditions • Arterial blood gas analysis • Referral to appropriate specialist
evaluations • Respiratory and airway • OSA rule out • Defer surgery until conditions are resolved
• Bleeding diathesis • Complete blood count or under control
• Chronic systemic illness • Electrocardiogram • Re-evaluate conditions
• Occult disorder • Chest radiograph • Seek consent to treat from the treating doctor
• Allergy • Allergy test • Anti-allergy medication
Patient’s informed • Signed informed consent • All components/parts of informed • Evaluate ethical, legislative conditions
consent • Identify patient’s needs, values, and goals decision-making • Contingency plan for risks, alternatives,
• Right information uncertainties
• Shared decision-making
Medication/ • Pain • Pain questionnaire • Analgesics
anaesthesia • Infection • Culture tests/immunoassays • Antiplatelet medications
clearance • Swelling • Clinical assessment • Prophylactic antibiotics
• Gastric emptying/bowel movements • Amnesia enhancement drugs
• Infective endocarditis • Reduction of volume of gastric and pH
Preoperative • Previous unpleasant dental experiences • Anxiety assessment (Spielberger • Consider deferring surgery if the anxiety is
anxiety • Sleeplessness State-Trait Anxiety Inventory (STAI), and not curtailed
• Nervousness, apprehension the Multiple Affect Adjective Checklist • Antianxiety medication (barbiturates)
• Helplessness (MAACL)) • Explanations of procedures in non-jargoned
• Psychological screening language
• Level of knowledge of the procedure • Enhancing coping skills
• Appraisal of surgical procedures
Social support • Lack of emotional support • Medical outcomes study social support • Emotional, practical, and informational
– Empathy, love, trust support survey (MOS-SS) support from family and friends
• Lack of guidance/instructional support • Adequacy of social support • Association and close network with family
– Appropriate instructions, advice, suggestions • Patient-reported quality of life (PRQL) members
• Lack of self-appraisal support • Dental impact of daily life
– Basic self-evaluation information • Activities of daily living (ADL)
• Lack of instrumental support
– Tangible aid and service
Orthodontic • Bracket and band breakage • Clinical evaluation • Addressing the condition
assessment • Orthodontic ligation
• Surgical splint fit
• Surgical hooks/K-hook robustness
Surgery • Third molar • Radiographic evaluation • Addressing the condition
• Bone conditions • Clinical evaluation • Removal of third molar 3–6 months prior to
11 Pre- and Post-surgery Patient Care Checklist and Patient Instruction
• TMJ evaluation surgery

• Ulcers, lip drying • Defer surgery until TMJ issue is resolved
Post-surgery Mental/cognitive • Mental health condition • Posttraumatic stress disorder (PTSD) • Ensure appropriate referrals for patients with
assessment • Emotional problem • Trauma Screening Questionnaire (TSQ) emotional or psychiatric problems
• Body dysmorphic disorder (BDD) • Body dysmorphic disorder questionnaires • Cognitive behavioural therapy
• Comparing body parts to others’ appearance • Level of Exposure-Dental Experiences • Antidepressant medications
• Camouflaging body parts Questionnaire (LOE-DEQ) • Psychoeducation, self-help books
• Suicidal thoughts/tendency • Support groups and websites
Postoperative pain • Face—lips, cheeks, muscles • Present Pain Intensity (PPI) • Plan effective pain management
management – Bruised face, tightness of jaws muscles, dry/ • Visual Analogue Scales (VAS) of the • Sepsis control
cracked lips, sore lips McGill Pain Questionnaire • Nasal decongestant
• Ear, nose, throat • Frequency, duration, and intensity • Postoperative neurovascular assessment and
– Nasal congestion, earache/irritated throat assessment monitor
• Teeth, alveolus, TMJ • Underlying pathology assessment • Consider antiviral therapy (acyclovir)
– Sore teeth • Sensations and pressure evaluation
– TMJ pain • Rule out HSV-I breakout
Oral prophylaxis • Foul odour • Oral hygiene evaluation • Professional oral cleaning
requirements/ • Excessive plaque accumulation • Identify source of infections • Oral toileting/brushing technique (oral
guidance • Food and beverage unable to clean • Wound healing evaluation irrigators and electric brushes)
• Bacteraemia • Reinforcing oral hygiene instructions
• Gingival and periodontal inflammation • Oral rinses (mouth washes)
Postoperative • Weight loss • Assess occult bleeding • Engage appropriate bleeding control
nutrition (fluid and • Constipation • Evaluate fluid loss via drains protocol
electrolyte balance) • Hypovolaemia • Assess excess bleeding intraoperatively • Parenteral nutrition
• Depression and postoperatively • Oral liquid nutritional supplements
• Vomiting • Patient’s progress assessment with
• Oliguria, confusion, and tachypnoea maxillofacial dietician
• Implement measures to counter vomiting
Orthodontic • Dental occlusion • Post-surgery radiographic assessment • Encouragement of elastic application
assessment • Guiding elastics difficult to place • Post-surgery clinical assessment • Bracket and band fixation as early and much
• Positioning of surgical splint as mouth opening allows
• Bracket and band fixation evaluation • Consider re-surgery
• Initiate orthodontic treatment as early as
possible
Surgery • Bone plating incorrect • Radiographic evaluation • Addressing the condition
11.2 Pre- and Post-surgery Checklist: Category, Conditions, Assessment Tools…
• Damage to alveolar segments • Clinical evaluation • Consider re-surgery

• TMJ malposition • Provide adequate instructions and
• Excessive facial swelling instruments for the recovery/postoperative care
• Bleeding team to cut the IMF wire in the case of
• Intermaxillary fixation (IMF) needs to be removed emergency
127
128 11 Pre- and Post-surgery Patient Care Checklist and Patient Instruction
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.
11.2.1 Systemic Conditions, Medication/Anaesthesia Clearance
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].
11.2.2 Psychological Assessment
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
11.2.3 Mental/Cognitive Assessment
Body dysmorphic disorder (BDD) or dysmorphophobia is a body-image perception

mental disorder characterized by persistent dislike or finding fault in some part of
their body to such extreme extent that the affected person takes exceptional mea-
sures to hide or camouflage the perceived dysmorphic part [9, 10]. Several causes
eliciting this aforementioned mental disorder need to be taken into account before
the actual contemplation of jaw surgery. Literature suggests that patient affected
with BDD seek aesthetic surgical enhancement at a prevalence rate as high as 15%
[11]. Also, studies have shown that individuals with BDD repeatedly consult aes-
thetic surgeons to change their appearance and often do not benefit or show improve-
ment in their condition even after performing multiple procedures [12]. It is prudent
to rule out BDD during the initial evaluation including symptom profile, comorbid-
ity patterns with depressive disorders, sociocultural factors, and neurological pat-
tern and must be further referred for pre-surgical psychological counselling or
psychiatric treatment. Studies have shown that individuals with BDD greatly benefit
from ‘pharmacologic treatment’ involving selective serotoninergic antidepressants
(fluoxetine and fluvoxamine) and tricyclics (clomipramine). These patients also
show improvement with ‘psychological intervention’ such as cognitive-behaviour
therapy that aims at altering certain specific beliefs and long-held assumptions that
underline the BDD [13].
11.2.4 Social Support
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
turn positively influences the recovery as the knowledge allows the patient to be
better equipped [16].
11.2.5 Postoperative Nutrition (Fluid and Electrolyte Balance)
During the postoperative recovery phase, a patient’s body undergoes a period of

limited supply of nutrition or starvation due to limited mouth opening, lack of appe-
tite, pain and discomfort, and delirium. If nutrition is not supplied, the body switches
to a ‘state of catabolism’ (breakdown of fat, protein, dehydration synthesis, and
endergonic reaction) in order to maintain a minimum basal metabolic rate.
Postoperative nutrition deterioration leads to alteration in body composition, weight
loss, reduction of total body water, fat and protein decrease, and a lean body mass
[17]. Some of the causes for the aforesaid conditions are enumerated in Table 11.1.
Adequate nutritional support can substantially reduce postoperative morbidity and
length of hospital stay [18]. A study concluded that the addition of a high calorie
liquid supplement to the dietary schedule helped the postoperative recovering
patient replenishes the nutrition level [17].
11.2.6 Patient’s Informed Consent
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].
11.2.7 Postoperative Pain Management
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].
11.2.8 Oral Prophylaxis Requirements/Guidance
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).
11.2.9 Orthodontic and Jaw Surgery
Orthodontic-related checklist is enumerated in Table 11.1. A comprehensive pre-

surgery orthodontic assessment is a prerequisite for achieving a consistently high-
quality surgical outcome. The orthodontic checklist pertains to three domains: (1)
bracket and wire, (2) tooth movement, and (3) surgical splint assessments. The
problems encountered during orthodontic phase of SFOA are explained, in detail, in
Chap. 12.
Some of the important medical conditions and its implications on pre- and
post-
surgery are mentioned in Table 11.1 along with the appropriate
management.
11.3 I nstructions for Patients and Care Givers: Dos

and Don’ts
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).
Dos and don'ts
Before surgery After surgery
Dos Don’ts Dos Don’ts
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
• Immediate post-surgery to 1 week

General well-being and diet ✓ Liquid diet ( soup)
✓ Drink plenty of water
✓ Maintain sufficient hydration
✓ Use toddler cups ( sippy cups) to drink or use
squeeze bottles that squirt fluid.
• Biting on hard , crunchy, and chewy food (e.g.,
• Biting on hard , crunchy, and • Week 1 to week 3 candies, popcorn, peanuts, meats)
• Get ample amount of rest
chewy food (e.g., candies, ✓ Follow soft diet (semi-solid) ( mashed
• Take all the medications as • Shower with hot water for at least a couple of
popcorn, peanuts, meats) potatoes, fish, mashed banana)
prescribed and directed days
• alcoholic beverages, Smoking ✓ Cold foods ( yoghurt, plane ice cream)
• alcoholic beverages, Smoking
✓ Protein shakes and multivitamin syrups
• Weeks 3-4 onwards
✓ Soft to normal diet (avoid eating hard and
chewy food)
✓ Noodles, rice (congee) , soft-bread
✓ Sliced apple, orange
• Warm saline rinses using syringes

Oral Hygiene
• Anti-bacterial, antiseptic mouth rinse
(Chlorhexidine, Listerine)
• Use a child-size tooth brush until mouth opening is
limited
• Purchase a new soft bristle • Apply generous amount of lip balm or petroleum
toothbrush jelly on lips too keep it from drying and bleeding
• Not following instructions • Brush or rinse/ gargle your mouth rigorously
• Rinse your mouth • Use tongue cleaner, preferably a small size
• Eating sticky food • Drink through straw as straw can lead to bleeding
• Maintenance of oral hygiene • Use additional oral swabs to keep your mouth clean
• Professional cleaning • Stock enough dental wax to protect raw wound
from arch bars or surgical wires
• Consider using automatic teeth cleaner/irrigators
(Waterpik®, Airfloss®) after one-week of surgery
• Use interdental brushes
• Powered toothbrush after one-week of surgery
Physical activity or ambulatory • Immediately after surgery

care ✓ minimal movement such as attempting to
open mouth
✓ Short walks, strength return activities are
encouraged during hospital stay
• Try to get minimal physical • Strenuous exercise, physical • One week after surgery
• Strenuous exercise, physical activity, brisk
exercise activity, brisk movements, ✓ Open and close your mouth more often
movements, driving vehicle for at least one month
• Allow ample amount of rest to driving vehicle for at least one ✓ Move jaw side to side and place one to two
• Heavy machinery operation
your body month fingers in between front teeth
• Contact sports
• • Heavy machinery operation • One month after surgery
✓ Place two to three fingers in between front
teeth
✓ Move jaw freely
✓ Commence gentle exercise, climbing a flight of
stairs
• Strong positive mental attitude • Unnecessary stress

Psychosocial response • Unnecessary stress • Strong positive mental attitude
• Seek family/friends support • Being negative
• Being negative • Seek family/friends support
• Performing meditation/yoga • Skeptical in attitude
• Skeptical in attitude • Make an attempt to seek answers
helps to relax your mind
Pain management/ wound

Recovery /swelling • Inform the clinic of unusual bleeding or tightness
around the face even after one week
• Report of any pain or • Use ice packs for the first 2-3 days • Fiddle with numbness
discomfort • Sleep with head elevated and pillow propped • Remove stiches
• Not following instructions • Intermittent moist heat could be used after 1-2 • Disturb clot
• Follow instructions : coping
skills days post-surgery • Hot fermentation over the swelling
• Gentle massage could be commenced after 2-3
days to relieve muscle spasms
Fig. 11.1 Before and after surgery dos and don’ts
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
If I had an hour to solve a problem I’d spend 55 minutes

thinking about the problem and 5 minutes thinking about
solutions.
—Albert Einstein
12.1 Introduction
Surgery-first orthodontic approach may pose potential complications ranging from

minuscule errors to the most harrowing complex problems that not only cause sig-
nificant damage to the hard and soft tissues but also require a remedial surgery.
Complications that can occur at various stages of SFOA treatment will be discussed
with regard to the planning and execution stages and also the adequate safety mea-
sures or resolution that could be implemented in order to counter the problems. A
reference guide on how to deal with the perils posed to both orthodontist and sur-
geon whilst contemplating SFOA will be discussed in detail.
12.2 Orthodontist-Related Complications and Management
12.2.1 Pre-surgery Phase
Complications arising from orthodontic mechanics are hardly encountered when

carrying out SFOA in this phase as the minimal or no active orthodontic treatment
carried out. So by that reason, practitioners of SFOA would face less complications
in this phase as compared to using the conventional surgery approach. It is essential
and important to assess the risks and potential complications that could be posed
still and be amply equipped with tools that can assist in positive resolution for the
effective and successful management of patient’s problems with SFOA.

https://doi.org/10.1007/978-3-030-18696-8_12
136 12 Potential Complications and Management of SFOA
These can be broadly described under the following categories:
1 . Etiological and clinical assessment.

2. SFOA planning (2D and 3D).
3. Orthodontic treatment execution.
4. Laboratory and splint fabrication.
12.2.1.1 Etiological and Clinical Assessment

A thorough evaluation of maxillo-mandibular structures soft and hard tissues is
essential as Xia et al. [1] reiterate the fact that jaw deformities occur as a result of
either congenital or acquired etiological factors or a combination of both. This could
arise from genetic abnormalities, deformations, intrauterine disruptions, infectious
diseases, or abnormal functions that lead to various types of jaw deformities (size,
position, orientation, shape, symmetry, and completeness) [2–4]. Failure to recog-
nize this aforementioned critical aspect of patient assessment along with a lack of
precise discernment of associated co-morbidities (e.g. chewing difficulty, sleep
apnoea, dysarthria, psychological impedance) would lead to complications in the
subsequent planning and execution. A checklist should be made comprising of skel-
etal, dental, soft tissue, and patient factors, and planning should be made in accor-
dance to the ‘one patient two problem (skeletal and dental) concept’.
Evaluation of psychosocial well-being with particular emphasis on body dys-
morphic disorder (BDD) [5] in individuals seeking jaw surgery for the correction of
physical defects is important, as Vulnik et al. in their study found that 10% screened
positive for BDD and advised for (1) a psychiatric evaluation whenever a patient
exhibits significant behavioural impairment and (2) to enforce a BDD screening
questionnaire prior to SFOA [6, 7].
12.2.1.2 SFOA Planning (2D and 3D)

Advancements and refinements are occurring in the 3D assessment and planning
arena of SFOA, but the application of face bow and articulator and other 2D modali-
ties of image capture still remains the preferred approach for jaw surgery planning.
Walker et al. emphasize that cases with facial asymmetry requiring the positioning
of temporomandibular joints relative to the maxilla should consider using highly
adjustable spirit level orthognathic face bow that allows more accurate records to be
made of patients with asymmetrical maxilla instead of a semiadjustable articulator
[8, 9]. In SFOA, since the malocclusion is still present, it is of the utmost impor-
tance to record the accurate position of the maxilla relative to the cranial base. This
is especially important if a two-jaw surgery is planned. This will improve the accu-
racy of mounting of occlusal models on the articulator for the development of a
more accurate prediction and surgical which will result in the most ideal surgical
outcomes [10].
In 3D planning, orientation of the skull composite model cannot be overem-
phasized (for further reading on NHP, please refer to Chap. 4). Several techniques
have been mentioned in the literature, such as 3D laser surface and digital gyro-
scope [11]. Further, complications encountered during the 3D planning (due to
12.2 Orthodontist-Related Complications and Management 137
inherent errors in the hardware and software) could be resolved by exhaustive

communication between the orthodontist and the surgeon and arriving at a clini-
cally feasible treatment plan. Plooij et al. recommend that since 3D image and 3D
fusion process are prone to errors, it is prudent to compare the 3D simulated
model with clinical assessment and to rely on experience to assess if the predica-
tions are acceptable [12].
12.2.1.3 Orthodontic Treatment Execution

The potential complications during orthodontic treatment execution could arise dur-
ing bonding of brackets, placing wires, and surgical splint try-in. During bonding of
brackets, the brackets are generally placed 1–6 weeks before the scheduled surgery,
and passive ligature wires are used to secure the brackets in the event of a debond.
During this phase, active orthodontic tooth movement is not desired, and, as such,
no active wire should be used. Any tooth movements at this stage will prevent
proper fitting of the surgical splint. It is prudent to use a passive ligation to avoid
such a problem. The placing of stainless steel ligation wire along with K-hooks is
preferred. On the day of surgical splint try-in, if the teeth have moved, the surgical
splint can be trimmed and adjusted to accommodate for minor tooth movement. If
tooth movement is significant, it will be best to repeat the procedure and fabricate a
new surgical splint taking into account the new tooth positions.
12.2.1.4 Laboratory and Splint Fabrication

3D splint design and fabrication have the ability to visualize the anatomical struc-
tures in three dimension and confirm the planning in 6 degree of freedom making it
highly precise. 3D printing material costs are steadily decreasing due to increase in
supply and large-scale production. The complications that arise with splint design
and fabrication and suitable resolution for the same are enumerated in Table 12.1.
12.2.2 Surgery Phase
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
Table 12.1 Orthodontics-related complications, causes, and resolution

Stage Complication Causes Resolution
Pre-surgery 1. Surgery planning is 1. Stepwise 1. Meticulous step-by-step
not accurate cephalometry, face procedure is important
2. Unable to establish bow transfer, and 2. (a) 3D composite images
two- or three-point model articulation are need to be accurately
contact in a not in sync recorded, and judicious use
transitional occlusion 2. (a) Creation of 3D of surgery planning
3. Splint ill-fitting composite image is software is important
during try-in not accurate (b) Skeletal
4. Distorted splint (b) Skeletal discrepancies should be
corrections are not corrected by planning
defined accurately proper osteotomies; once
3. (a) Not enough the skeletal problem is
clearance between corrected, every effort
splint and the brackets should be made to establish
causing rocking of dental contact points to
splint establish a orthodontically
(b) Premature tooth treatable occlusion
movement leading to 3. (a) Providing enough
ill fit of the wafer clearance between splint
4. (a) Warping of and bracket
splint. Ill fabrication (b) The use of passive
or warping of ligature wires to avoid
stereolithographic premature tooth movement
models 4. (a) Selection of better
(b) Poor-quality print material
print material
During surgery 1. Bracket debonding 1. (a) Inadvertent 1. (a) Delicate use of
2. Ligature wire surgical instrument surgical instruments
breakage handling (b) Thorough bonding
3. Ill-fitting surgical (b) Incomplete/poor procedure should be
wafer bonding implemented
4. Teeth not in 2. Ligation of bite 2. Use of K-hooks to ligate
position as planned wafer to the ligature bite wafer to the bracket
wire 3. Soak the wafer in water
3. Not enough to avoid ill-fitting due to
moisture is provided warping
for the wafer resin 4. Use of passive ligature
4. Use of arch wires wire, if need arises of using
for too long such that arch wires, use passive arch
the teeth have moved wires to avoid tooth
movement
(continued)
12.2 Orthodontist-Related Complications and Management 139
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
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.
12.2.3 Post-surgery Phase
Some of the common challenges encountered during post-surgery are enumerated

in Table 12.1. ‘Occlusal instability’ could be one of the most challenging entities
encountered in SFOA. In order to minimize the instability of the transitional occlu-
sion, one should initiate adjunctive orthodontic treatment as soon as possible post-
operatively to transfigure the transitional occlusion into the solid final occlusion.
The possible solutions to resolve transitional occlusion are detailed in Table 12.1.
12.3 Surgery-Related Complications and Management
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 Surgery-related complications, causes, and resolution

During 1. Haemorrhage 1. Severance of major 1. (a) Working meticulously with
surgery 2. Proximal segment vessel a thorough knowledge of major
fractures 2. (a) Non-vigilant vessels course
3. Oro-antral attention to surgical (b) Cauterization
communication technique (c) Microvasculature
4. Trauma (b) Overzealous use of reconstruction surgery
(a) Gingiva and surgical instrument (d) Consider transfusion of red
mucosa laceration and (c) Frail bony segments bold cells and fresh frozen
ulceration (d) Third molar plasma
impacted 2. (a) A thorough attention to
3. Poor access design with surgical technique
less considerations on the (b) Proper use of surgical
bony anatomy of the instruments
maxillary antrum (c) Pre-treatment assessment
4. Surgical drill ill of bone condition
manipulation (d) Removal of third molars at
least 3–6 months before surgery
to allow proper bone healing
3. Attempt for primary closure,
try ribbon gauze soaked in
whiteheads varnish, or bilateral
palatal flap surgery
4. Petroleum-based jelly or lip
lubricants during the operation
may prevent lip lesions and
ulcerations
(continued)
12.3 Surgery-Related Complications and Management 141
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
Establishing Risk assessment and

Risk impact
priorities characterization
Risk response
Risk prevention Risk mitigation Risk acceptance Risk transference
• 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
Fig. 12.1 Risk management process for problems encountered in SFOA

References 143
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
1. 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.
2. Gateno J, Alfi D, Xia JJ, Teichgraeber JF. A geometric classification of jaw deformities. J Oral
Maxillofac Surg. 2015;73:S26–31.
3. Gateno J, Xia JJ, Teichgraeber JF, Christensen AM, Lemoine JJ, Liebschner MA, et al. Clinical
feasibility of computer-aided surgical simulation (CASS) in the treatment of complex cranio-
maxillofacial deformities. J Oral Maxillofac Surg. 2007;65:728–34.
4. 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;65:248–54.
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
Research is to see what everybody else has seen, and to think

what nobody else has thought.
—Albert Szent-Gyorgyi
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

https://doi.org/10.1007/978-3-030-18696-8_13
SFOA Outcome
146
Assessment
Clinical Outcome Psychological/Social Health resource

Assessments Assessments utilization
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
deformity orthodontic deformities

treatment
(continued)
147
148
Method of
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
mandibular
prognathism
Method of
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
models could be
used to improve
facial symmetry
with bimaxillary
surgery
(continued)
149
150
Method of
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
26.2 ± 4.4 years) deterioration stage

of OQLQ score
Method of
Brucoli/2018 Prospective 33 pts., conventional SFOA in Conventional Psychosocial Oral Health Impact SFOA positively
[16] study jaw surgery (n, 25; skeletal Class surgery well-being, Profile questionnaire, influence the
25.0 ± 5.5 years) and III dentofacial self-esteem, Temperament and compliance and
SFOA (n, 8; deformities anxiety, and Character Inventory psychological
35.6 ± 13.4 years) quality of life (TCI), Resilience Scale status of the
for Adults (RSA), patients
Italian Validation of the
Psychosocial Impact of
Dental Aesthetics
Questionnaire
(PIDAQ), Beck
Depression Inventory
second edition (BDIII),
the Rosenberg
Self-Esteem Scale
(RSES)
Zingler/2017 Prospective 9 pts. (26.7 years) SFOA in Pre-treatment Psychological and Orthognathic quality SFOA has positive
[17] cohort study skeletal Class baseline biological changes of life (OQLQ) impact on patient’s
III and Class II in SFOA questionnaire, Sense psychosocial
dentofacial of Coherence 29-item status.
deformities scale (SOC-29), and SFOA elevated

longitudinal day-to- levels of bone
day questionnaire IL-1 remodelling factors
b, IL-6, TGF b 1–3,
MMP-2, and VEGF
were assessed in
crevicular fluid by
bead-based multiplex
assays
151
(continued)
152
Method of
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)
Method of
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
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.
13.2.1 Orthodontic Treatment Difficulty Level: Minimal

to Moderate
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.
13.2.2 Orthodontic Treatment Difficulty Level: Severe
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.
• More than one cusp width posterior crossbite.

• Large overbite with anterior teeth inclination that need extensive orthodontic
mechanotherapy post-surgery.
• Severe crowding or malocclusion requiring teeth extraction.
• Musculoskeletal aberrations precluding orthodontic tooth 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
treatment time in the no pre-surgical orthodontics group in comparison to pre-

surgical orthodontics group. They concluded that the resulting decrease in time
could be due to the following reasons: (1) skeleton and soft tissue surrounding the
teeth are brought back to normalcy, thus allowing the swift orthodontic tooth move-
ment in a relatively anatomically normal contiguity; (2) orthodontic tooth move-
ment increases when the teeth are in non-occlusion (i.e. unlocking occlusion)
removing occlusal interferences, thus enhancing expediency of alignment of teeth,
arch levelling, and coordination; and (3) increased bone turnover post-surgery
(RAP) augmenting orthodontic tooth movement.
13.3 Stability of SFOA Versus Conventional Jaw Surgery
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.
13.4 Quality of Life Outcomes and Psychological Status for SFOA
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,
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.
13.5 SFOA: Evidence-Based Practice
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
SFOA as a new treatment philosophy is experiencing a state of evolution, and it is at the

foothills warming up itself before the final ascension—as Thomas Kuhn in his philo-
sophical book The Structure of Scientific Revolutions remarks that that every single
scientific field experiences a periodic, non-linear, revolutionary accrual of information
referred to as ‘paradigm shifts’, and often the ‘alternate concepts’ (in this case, SFOA)
are looked upon with initial contempt and scepticism, but as superfluous favourable
evidence is gathered, the ‘alternative concepts’ garner widespread ‘peer-group’ con-
sensus and is bestowed its due credibility, dismissing the initial disregard [39].
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Future of Surgery-First Orthognathic
Approach 14
I never think of the future- it comes soon enough.

—Albert Einstein
14.1 Introduction
Future of SFOA is based on the rapid developments in the three-dimensional imag-

ing technology aiding diagnosis and management of jaw surgery [1–3]. The
improved application of computer-aided design (CAD) and computer-aided manu-
facturing (CAM), in particular, rapid prototyping (RP), has made the fabrication of
the surgical splints a reality. 3D imaging coupled with 3D imaging analysis software
and CAD/CAM technology has seamlessly transformed fabrication of surgical
splints from a labour-intensive laboratory procedure to an easy, reliable, and quick
chair-side clinical affair [4–7].
For ease of understanding the integration of technology in the diagnosis and
management of jaw surgery, it will be divided into the following parts (Fig. 14.1):
• 3D surface photomapping and soft tissue simulation.

• Virtual surgical planning (VSP).
• ‘Tools of transfer’ for surgery planning.
• 3D printing/rapid prototyping.
• Augmented real-time and virtual surgical navigation.
14.2 3D Image Acquisition and Diagnosis
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

https://doi.org/10.1007/978-3-030-18696-8_14
162 14 Future of Surgery-First Orthognathic Approach
3D photos Creation of
CBCT Scan ‘Composite Model’
+ (3D Soft tissue+
3dMD face system
Trios 3 Shape Scan 3D Dentition+
(3dMD Inc.)
3D Skeleton)
Virtual Surgical Splint

3D printer Virtual Surgical
/surgical cutting
Steriolithography Planning Software
guides construction
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
3 Invivo5 Anatomage • Automatic volume reconstruction http://www.anatomage.com/invivo5 No

• High-quality 3D rendering
• Airway analysis
4 Proplan CMF Materialise • Plan for orthognathic procedures and http://www.materialise.com/en/medical/ No
soft tissue simulations software/proplan-cmf
• Able to create 3D anatomical models and
surgical guides
5 Osirix (v8.0.2) Pixmeo SARL • Most widely used medical viewer in the http://www.osirix-viewer.com Free
world (35% growth in 2016)
• Currently only supported on Apple Mac
OS
6 VSP® Orthognathics 3D Systems • Complete virtual planning service that http://www.medicalmodeling.com/solutions- No
eliminates the need for traditional model for-surgeons/vsp-technology/
surgery vsp-orthognathics/
• Partnered with Dolphin Imaging for
surgical planning
(continued)
163
164
Sr. Free to
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
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
Carlsbad, CA • Support 3D navigation devices

• Fast multithreaded and distributed
rendering
18 Analyze AnalyzeDirect, • Advanced image visualization and https://analyzedirect.com/analyzepro/ No
Lenexa, Ann Arbor, volume rendering
MI • Multimodality image fusion
19 Maxilim Medicim, Bruges, • Specializes in maxillofacial surgery www.medicim.com No
Belgium • Specific for craniomaxillofacial
procedure
20 Voxim IVS Solutions, • Volume-based registration Voxim.software.com No
Chemnitz, Germany • Virtual osteotomies possible at cross-
sectional image views
21 3dMD vultus Atlanta, GA • Specializes in oral and maxillofacial www.3dMD.com No
surgery
• Customized 3D prints
(continued)
165
166
Sr. Free to
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)
14.3 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.
14.3 Virtual Surgical Planning (VSP)
The virtual surgical planning is performed on a computer having surgical planning

software. Several simulation software are available for the virtual surgical simula-
tion for jaw surgery. Some of the commonly used software are listed in Table 14.1.
These software are capable of several functions including (Figs. 14.2 and 14.3):
(a) Image segmentation (from DICOM files to region of interest).

(b) 3D cephalometric and anthropometric analysis.
(c) Repositioning of osteotomy segments according to the surgical plan.
(d) Evaluation of occlusion.
(e) 3D surface photomapping and soft tissue simulation.
(f) 3D surgical splint design.
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
Summary: 3D SFOA Planning : CAD/CAM Technology
Photogrammetry System
Trios 3 Shape Intraoral Scanner

3dMD Photogrammetry System
Proplan Software
Virtual Surgical Planning Software Jaw Surgery Virtual Planning Outcome
CBCT scan
Immediate post-surgery Outcome 3D printed Wafer 3D Printer-Steriolithography System Virtual Splint/Surgical Wafer
Fig. 14.3 Summary of 3D SFOA planning using CAD/CAM technology

14.4 ‘Tools of Transfer’ for Surgery Planning 169
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].
14.4 ‘Tools of Transfer’ for Surgery Planning
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.
14.4.1 CAD/CAM Splints with Extra-Oral Bone-Borne Support

(EOBS)
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:
1. Elimination of error-prone and time-consuming treatment planning steps, such

as face-bow transfer, cephalometric assessment, and model surgery [5].
2. Elimination of positioning devices such as surgical splint that takes dental occlu-
sion into account for the stabilization of osteotomy cuts. The non-dependency of
occlusion for surgical fixation is an added advantage, especially in SFOA cases,
as there is usually suboptimal intermaxillary cuspation for the proper fit of the
surgical splint.
3. Extra-oral bone-borne support splint relies on several techniques such as:
(a) Patient-specific implants (PSI) are manufactured via CAD/CAM technology
and are used when fixing the repositioning of the maxillo-mandibular
complex [5].
(b) Interactive image-guided visualization display (IGVD) to transfer virtual

maxillary planning precisely in real time [7].
(c) CAD/CAM enabled fabrication of ‘surgical cutting guides’ and ‘titanium
fixation plates’ that allow maxilla reposition accurately without a ‘surgical
splint’ [21, 22].
14.5 3D Printing/Rapid Prototyping in Surgery
3D printing, also known as additive manufacturing or rapid prototyping, is a revolu-

tionary method of reconstruction of a 3D object by using 3D printing processes such
as stereolithography (SLA), selective laser sintering (SLS), fused deposition model-
ling (FDM), MultiJet printing (MJP), ColorJet Printing (CJP), Plastic Jet Printing
(PJP), and Direct Metal Printing (DMP) using a wide variety of materials. Some of
these materials include acrylic, silicone, plaster, hydroxyapatite, and cobalt chro-
mium [23, 24]. 3D printing has made tremendous advancements that we are able to
better visualize malformations (77%), enhance refinement in guides and templates
(53%), decrease operating time (52%), and have positioning improvements and
even improvement in the transfer of information to patients (13%). The downside of
3D printing still revolves around the cost of the equipment, additional preoperative
planning, untoward reaction of the print material, and complex coordination. These
are the usual barriers that hinder the adaptation of using 3D printing [25–27].
14.6 Augmented Real-Time and Virtual Surgical Navigation
3D-assisted surgical navigation is a surgical modality based on synchronizing the

intraoperative position of the surgical instruments with the 3D images of patient’s
craniofacial structures (Table 14.2) [28, 29]. Extra-oral reference points (fiduciary
markers) of the patient are used as navigation points and are synchronized with the
virtual points on the reconstructed patient’s image (point to point registration) on a
‘navigator screen’ of proprietary navigation software [30]. Several surgical naviga-
tion software are commercially available and are listed in Table 14.2. Real-time
navigation has many potential applications in the field of jaw surgery, such as (1)
tracking the precise location of the surgical instrument, thereby reducing damage to
the critical neurovascular tissues; (2) help to position the osteotomized bony seg-
ments in a planned position, hence reducing positioning errors; (3) offset the usage
of two splints (intermediate splint) in two-jaw surgical cases, as the movements of
the maxilla can be controlled by the navigation probe system; and (4) the surgeon
can control the maxilla-mandibular complex freehand in 3D space with the aid of
the surgical navigation system, hence providing adequate accuracy for a highly pre-
cise surgery [2, 31]. Advancements in the augmented real-time and virtual surgical
navigation have prompted more companies to invest in this field which is estimated
to have a market capitalization valued at USD 734.5 million, and it is projected to
see a rise in the demand for surgical navigation systems in the near future [32].
Table 14.2 Surgical navigation systems
Free
Sr. Name of the navigation to
No. system platform Company Highlight Website use?
1 3D Guidance trakSTAR Ascension Technology Corporation • 3D electromagnetic tracking system http://www.ascension-tech. No
(120 Graham Way, Suite 130 boasting reliability, versatility, and ease of com/products/#3d-guidance
Shelburne, VT 05482 USA) use
• Up to four sensors provide optimal
tracking volume for 3D medical
navigation applications
2 Polaris Spectra NDI Medical Solutions (103 Randall • Advanced tracking algorithms provide http://www.ndigital.com/ No
Drive Waterloo, Ontario, Canada N2V exceptional accuracy medical/products/
1C5) • Able to track both active and passive polaris-family/
wireless tools
3 StealthStation AxiEM Medtronic, Inc. Surgical Technologies, • Adheres to patient’s skin, eliminating the http://www. No
System Neurosurgery (826 Coal Creek Circle need for a head holder stealthstationaxiem.com/
Louisville, CO 80027 USA) • Flexibility using a simple plug and play
design
4 Stryker NAV3i Stryker® • Navigation camera arm with large range http://www.stryker.com/ No
Navigation Platform (Stryker Global Headquarters of motion en-us/products/
2825 Airview Boulevard • 32″ high-definition surgeon’s monitor OREquipmentConnectivity/
14.6 Augmented Real-Time and Virtual Surgical Navigation
Kalamazoo, MI 49002 USA) with HDMI output SurgicalNavigation/

• Can be used in conjunction with eNlite SurgicalNavigationSystems/
system as a mobile platform to secure the Nav3i/index.htm
camera and monitor
5 Curve™ Image Guided Brainlab AG (Olof-Palme Straße • Two 27″ monitors with 16:9 screen ratio https://www.brainlab.com/ No
Surgery 981,829 Munich, Germany) • 1920 × 1080 pixels per display providing en/surgery-products/
full HD screen resolution overview-platform-products/
• Smart ergonomics allow easy curve-image-guided-surgery/
transportation and storage in the operating
theatre
(continued)
171
172
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)
References 173
14.7 Conclusion
As advancement in technology brings further refinement to computer-aided surgical

simulation, it will not be long before this will replace the manual or analogue meth-
ods of planning. As the cost of rapid prototyping and 3D printing comes down and
further refinements are made to the usability and accessibility of such systems, it
will make the practice of SFOA easier, more efficient, and safer for both patient and
practitioner alike.
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Surgery-First

A Clinical Guide to a New

ISBN 978-3-030-18695-1 ISBN 978-3-030-18696-8 (eBook)

© Springer Nature Switzerland AG 2019

Dedication from Dr. Chai Kiat Chng:

1 Introduction to Surgery-First Orthognathic Approach (SFOA) ���������� 1

4 Biomechanical Principles of Surgery-­First Orthognathic Approach������ 23

9 Management of Skeletal Class III Malocclusion with

13 Outcome Assessment of Surgery-First Orthognathic Approach ���������� 145

We are not makers of history. We are made by history.

Surgery-first orthognathic approach is an emerging science whose roots can be

1.2  verview of Surgery-First Orthognathic

© Springer Nature Switzerland AG 2019 1

Pre-surgical orthodontics and surgery-related orthodontics, in general, were not

Fig. 1.1 Surgery-first orthognathic approach timeline

2009 Nagasaka et al Significant reduction of treatment time.

• On a technique front: Pre-surgical orthodontics to eliminate dental compensation

1.3 Revival of Surgery-First Orthognathic Approach

1. Pre-surgical orthodontics is a prerequisite for conventional jaw surgery for arch

Following the commentary of Dr William Bell that conventional jaw surgery is

accompany substantial clinical evidence to prove the claims. Subsequently, nearly

1.4  omparison of Conventional and Surgery-First

Diagnosis is not the end, but the beginning of practice.

2.2  rthodontic and Surgical Considerations: Case

Surgery-first orthognathic approach (SFOA) is fast becoming an accepted modality

© Springer Nature Switzerland AG 2019 7

SFOA: Diagnosis and treatment planning

Pre-surgical Jaw Distraction

Sagittal Vertical Transverse

Extraction Non-extraction Single Jaw Double Jaw

Fig. 2.1 Routine workflow of surgery-first orthognathic approach

• In sagittal plane—mild proclination or retroclination of teeth

More complex cases can be undertaken by an experienced practitioner for

• Pre-surgical complexities (skeletal, dental, and soft tissue)

• Orthodontic-driven (see Sect. 2.2.1)

All four first premolar

Protruded maxilla + Le Fort I set-back or

Lower first premolar Set-up occlusion in

Set-up occlusion Consider using TPA

Skeletal scissor bite >

Anterior segmental lower incisors

2.2.3 One Patient Two Problem Concept

2.3  onventional Jaw Surgery Planning: Paper Surgery

efficient planning and execution leading to the correction of maxilla-mandibular

Fig. 2.4 Schematic illustration of 2D-assisted SFOA planning

2.4 3D Virtual Surgical Planning and 3D Splint Fabrication

Strategic planning with emphasis on careful considerations such as requirements

The skeleton is a record of past events and an oracle of future

Harold M. Frost, an American orthopaedic surgeon, first described regional

3.2 Regional Acceleratory Phenomenon

The BMUs respond to various biomechanical stimuli and are characterized by

© Springer Nature Switzerland AG 2019 15

Amino acids, Cytokines,

pressure, increased GCF activity

disturbance, increased tissue

nitrogen oxide (NO)

Rapid Wallerian degeneration

Bleeding, Inflammation, chemotaxis,

fibrosis, cell turnover

Resorption, formation, osteoblast

3.2.1 Systemic Acceleratory Phenomenon (SAP)

Mueller, Schilling, and team at the University of Heidelberg, Germany, conducted a

3.3  steotomy- and Corticotomy-Assisted Tooth Movement

significantly influences tooth movement [9–13]. Corticotomy is thought to induce a

1 Introduction to Surgery-First Orthognathic Approach (SFOA) �� 1

4 Biomechanical Principles of Surgery-First Orthognathic Approach�� 23

9 Management of Skeletal Class III Malocclusion with

13 Outcome Assessment of Surgery-First Orthognathic Approach �� 145

1.2 verview of Surgery-First Orthognathic

1.3 Revival of Surgery-First Orthognathic Approach

1.4 omparison of Conventional and Surgery-First

2.2 rthodontic and Surgical Considerations: Case

2.2.3 One Patient Two Problem Concept

2.3 onventional Jaw Surgery Planning: Paper Surgery

2.4 3D Virtual Surgical Planning and 3D Splint Fabrication

3.2 Regional Acceleratory Phenomenon

3.2.1 Systemic Acceleratory Phenomenon (SAP)

3.3 steotomy- and Corticotomy-Assisted Tooth Movement

3.4 urgery-First Orthognathic Approach’s

4.2 Six Degrees of Freedom (6DoF)

4.2.1 Natural Head Position: 2D and 3D

4.3 onsiderations of Translational (Sagittal, Transverse,

Traditional analogue techniques such as 2D radiography (lateral and postero-

4.3.1 Virtual Surgical Planning

Advancements in computed tomography (CT) imaging and CAD/CAM (computer-

5.2 Pre-surgical Orthodontics

5.2.1 Orthodontic Appliances (Brackets and Arch Ligation)

5.3 Pre-surgical Preparation

5.3.1 Determination of Transitional Occlusion

5.3.1.1 Prerequisites of a Transitional Occlusion

5.3.2 Surgical Splint Fabrication, Intermaxillary Fixation

5.3.2.1 Surgical Splints Duration and Purpose

5.4 Post-surgery in Surgery-First Orthognathic Approach

5.4.1 Post-surgical Orthodontic Considerations

6.2 ype of Surgery with Indications, Complications,

7.2 keletal Class I Malocclusion SFOA Treatment

7.3 Case Report

7.3.1 Treatment Objectives

7.3.2 Surgical Plan

7.3.3 Treatment Progress

Figure 8.1 explains the Class II skeletal deformity characterization in three-

8.2 Treatment of Various Skeletal Class II Cases