Current status of surgery first approach (part II): precautions and complications

Abstract

The choice of surgical technique in orthognathic surgery is based primarily on the surgical treatment objectives (STO), which is a fundamental component of the orthognathic treatment process. In the conventional orthodontics-first approach, presurgical planning can be performed twice, during the preorthodontic (initial STO) and presurgical phases (final STO). Recently, a surgery-first orthognathic approach (SFA) without presurgical orthodontic treatment has been introduced and combined initial and final STO at the same time. In contrast to the conventional surgical-orthodontic treatment protocol that includes preoperative orthodontics for dental decompensations to maximize stable postoperative occlusion, the SFA potentially shortens the treatment period and minimizes esthetic concerns during the decompensation period because skeletal problems are corrected from the beginning. The indications for the SFA have been proposed in the literature, but no consensus exists. Moreover, because dental occlusion of the pre-orthodontic arches cannot be used as a guide for establishing the surgical treatment plan, there are fundamental limitations in accurate prediction of postsurgical results in the SFA. Recently, the concepts of postsurgical orthodontic treatment are continuously changing and evolving to overcome this inherent limitation of the SFA. The elimination of presurgical orthodontics can change the paradigm of orthognathic surgery but still requires cautious case selection and thorough discussion and collaboration between orthodontists and surgeons regarding the goals and postoperative management of the orthognathic procedure.

Keywords: Complications; Orthodontics; Orthognathic surgery; Stability; Surgery first.

Fig. 1

A case with surgery first approach (SFA). An 18-year-old female patient had been successfully treated by two jaw surgery followed by the 20 months of postsurgical orthodontics

Fig. 2

Overall concept of the SFA compared to the conventional approach. Instead of dental decompensation using the orthodontic treatment before surgery, SFA utilizes more surgical approaches for dental decompensations (red arrow, orthodontic treatment; black arrow, surgical movements)

Fig. 3

A case with the conventional approach (21-year-old male). After 4 months of presurgical orthodontics, Le Fort I osteotomy and bilateral sagittal split ramus osteotomy for mandibular setback had been performed. The overall treatment was finished after the 2 months of postoperative orthodontics

Fig. 4

An example of mandibular relapse after SFA. Pogonion position at the immediate postoperative mark (broken arrow), significantly moved forward after surgery with SFA (solid arrow) without any evidence of temporomandibular joint problems

Fig. 5

Presurgical orthodontic preparations for the SFA (a, b, c) versus the conventional approach (d). Arch bars (a), brackets with maxillomandibular anchor screws without archwire (b), or light rectangular stainless steel wires are frequently used in the SFA, whereas strong rectangular surgical wires with surgical hooks are commonly used in the conventional approach (d). Photos located in the left column, before surgery; middle column, immediately after surgery; right column, at the time of debond

Fig. 6

a For the SFA, it is difficult to passively adapt the surgical rectangular wire to the irregular dentition. b To maintain passivity of the surgical archwire, not all the teeth are bracketed. c 016 × 016 light rectangular wire with MMF screws are commonly used for surgery-first cases

Fig. 7

An example of suggestions for the use of surgical archwires for surgery-first and conventional approaches for orthognathic surgery

Fig. 8

Failed brackets (arrows) are investigated in the operating room using intraoperative radiographic images (a lateral; b frontal image)