Treatment duration and factors associated with the surgery-first approach: a two-center study

Improvement of the Facial and Dental Esthetics With Surgery-Only Approach

With the development and introduction of orthodontic techniques and surgical protocols, modern patient prototypes are emerging. This paves the way for new approaches to the treatment of dentomaxillofacial deformities. The aim of the authors' study is to determine the appropriate timing and procedure for orthognathic surgery and to obtain the best patient and physician-oriented results. It is stated that surgery first and surgery only approaches are protocols that increase the motivation for treatment, with esthetic improvement being the priority. In this case report, the treatment of the authors' patient, who complained of asymmetry and planned to have a prosthetic restoration after correction of the skeletal deformity, with only a surgical protocol, is described. Treatment of dentomaxillofacial deformities involves a comprehensive analysis of patient, orthodontist, and surgeon-specific variables. Within appropriate indications, only a surgical approach can be an ideal approach for patients and specialist physicians in a short time.

Outcome measures of the surgery first approach for orthognathic correction of dentofacial deformities

In the surgery-first approach (SFA), orthognathic surgery is performed without the need for presurgical orthodontic treatment. This study was aimed at assessing the treatment durations and occlusal outcomes for a consecutive cohort of patients, with a range of dentofacial deformities, who had completed orthognathic treatment using SFA. The duration of orthognathic treatment was measured. The overall change in occlusion, and the quality of the final occlusion, were evaluated using the patients' study casts. A single, independent, calibrated operator carried out the occlusal scores, using the validated Peer Assessment Rating (PAR) index. This was repeated to test intraoperator reliability. A total of 51 patients completed surgery-first treatment during the study period. The mean (range) age at surgery was 23.3 (15-47) years. The pre-treatment skeletal jaw relationship was Class III in 39 cases, and Class II in 12 cases. The mean (SD) overall treatment duration was 11.7 (5.7) months. The intraexaminer reliability of assessing the occlusion was high. The PAR scores confirmed a significant improvement in the quality of occlusion at the completion of treatment, which compares favourably with previous studies on the conventional orthodontics-first approach. The surgery first approach can be effective at correcting both Class II and Class III malocclusion types with reduced treatment times.

Three-Dimensional Evaluation of Skeletal Stability following Surgery-First Orthognathic Approach: Validation of a Simple and Effective Method

Background  The three-dimensional (3D) evaluation of skeletal stability after orthognathic surgery is a time-consuming and complex procedure. The complexity increases further when evaluating the surgery-first orthognathic approach (SFOA). Herein, we propose and validate a simple time-saving method of 3D analysis using a single software, demonstrating high accuracy and repeatability. Methods  This retrospective cohort study included 12 patients with skeletal class 3 malocclusion who underwent bimaxillary surgery without any presurgical orthodontics. Computed tomography (CT)/cone-beam CT images of each patient were obtained at three different time points (preoperation [T0], immediately postoperation [T1], and 1 year after surgery [T2]) and reconstructed into 3D images. After automatic surface-based alignment of the three models based on the anterior cranial base, five easily located anatomical landmarks were defined to each model. A set of angular and linear measurements were automatically calculated and used to define the amount of movement (T1-T0) and the amount of relapse (T2-T1). To evaluate the reproducibility, two independent observers processed all the cases, One of them repeated the steps after 2 weeks to assess intraobserver variability. Intraclass correlation coefficients (ICCs) were calculated at a 95% confidence interval. Time required for evaluating each case was recorded. Results  Both the intra- and interobserver variability showed high ICC values (more than 0.95) with low measurement variations (mean linear variations: 0.18 mm; mean angular variations: 0.25 degree). Time needed for the evaluation process ranged from 3 to 5 minutes. Conclusion  This approach is time-saving, semiautomatic, and easy to learn and can be used to effectively evaluate stability after SFOA.

Factors affecting duration of post-surgical orthodontics in the Surgery First/Early Approach: A retrospective study

BACKGROUND

Surgery First Approach (SFA) and Surgery Early (SE) are considered promising alternatives, compared to the conventional three-stages orthodontic-surgical approach, for treatment of dento-maxillofacial deformities. However, many features need further study, like the role of the orthodontist. Aim of the study was to analyse the clinical characteristics of patients who underwent SFA and SE, and if differences in duration of orthodontics could be influenced by clinical features.

METHODS

A retrospective research was performed on patients who met the inclusion criteria for SFA (31) and SE (12), of the total of patients affected by dento-facial deformities in our Unit (191) in the period 2012-2017. After collection of clinical data, duration of orthodontics, age, pre-treatment PAR Index, ANB angle, amount of the curve of Spee were compared. A regression analysis evaluated if these clinical parameters, together with type of bracket and type of intervention, could influence the duration of post-surgical orthodontics.

RESULTS

All patients who performed the SFA/SE were affected by class III, II and active Unilateral Condylar Hyperplasia (22% of total population). Pre-treatment mean differences of age (p = 0.0518), PAR Index (p = 0.0916), curve of Spee (p = 0.1006) between groups were not statistically significant. A statically significant difference was found for the overall duration of therapy, for the significant shorter duration of pre-surgical orthodontics, while the difference of post-surgical orthodontics duration was not significant (p = 0.4753). Type of bracket (rho=-0.19039, p = 0.266) and intervention performed (rho=-0.11522, p = 0.5034) were not correlated with duration of post-surgical orthodontics, as well as pre-treatment PAR Index, ANB angle and depth of the curve of Spee.

CONCLUSIONS

Surgery First/Early Approach is a therapeutic choice that could be performed only in patients affected by specific malocclusions and who exactly meet indications. Protocol and post-surgical occlusal stability are factors that should influence the duration of therapy more than clinical characteristics.

The Application of the Divine Proportion for the Construction of the Visualized Treatment Objective in Craniofacial Surgery

ABSTRACT

Aesthetics and function of maxillofacial district are closely related and could interfere with patient psychological conditions. The aim of this paper is to describe and to analyze the procedures necessary for a proper surgical visualized treatment objective (VTO) realization through the use of the tracing on lateral head film, applying the divine proportion (or golden ratio) in certain steps. The method described is easy to realize, cheap and help both orthodontist and maxillo-facial surgeon to communicate each other and to the patients.For the following article, digital research and handheld research on surgical VTO planning for patients with skeletal or dentoalveolar severe deformities managed by surgeons and orthodontics were used. The research included articles in English published on dental and maxillofacial surgery journals.The surgical VTO consists of a "previsualization" of the objectives in order to make the desired changes for the individual patient. The result can thus be visualized and pre-evaluated rather than just imagined by the mind's eye. To simplify the procedure, the surgical VTO has been divided into 11 steps. The accurate model of the surgical result is fundamental in the treatment of dentofacial deformities. These predictions are intended to guide the treatment towards the desired result, to give the patient a reasonable preview of the outcome, and to ensure communication between the orthodontist and the surgeon.This technique proves to be effective in planning surgical treatment and it allows the clinician to view changes before, during, and after orthognathic surgery. The skeletal, dental, and aesthetic complete cephalometric evaluation is the key point to the long-term success of the results.

An orthodontic index assessment and its relationship with total treatment time in surgery first orthognathic approach: an observational study

BACKGROUND

The aim of this study is to highlight the connection between orthodontic difficulty before surgical treatment and in the transient malocclusion as evaluated by the mean of the ICON score and total treatment time in SFA.

MATERIALS

For each patient, the ICON score was evaluated pre-operatively and on the 3rd post-operative day in order to assess the orthodontic difficulty of pre-surgical occlusion and the transient malocclusion.

RESULTS AND CONCLUSION

Our group of patients at the preoperative stage showed score values between hard and very hard with only one patient scored as "easy" and nine "medium" patients. All scores lowered after surgical treatment. This confirms that the surgery first approach can change a malocclusion from not orthodontically treatable to an orthodontically treatable one. In our study, this was objectified by improvements in the ICON score. In the conventional three-phase approach of orthognathic surgery the total treatment time found in literature is around 18-36 months. In our study, even the most difficult cases do not have a duration of more than 15 months This demonstrates that the surgery-first approach can reduce the total treatment time even in more severe cases.

Current concept of the surgery-first orthognathic approach

Traditional orthognathic surgery has long been performed after presurgical orthodontic treatment. Despite some concerns, the surgery-first orthognathic approach (SFOA) or surgery-first approach (SFA) without presurgical orthodontic treatment has gradually gained popularity. In recent years, several articles dealing with the concepts of the SFA have been published worldwide. However, the SFA has not yet been standardized, and many surgeons use slightly different protocols and concepts. This review article discusses the beginning and evolution of the SFA and its current concepts, including some opinions based on the authors’ clinical experiences over the last 15 years. According to recent investigations, the SFA could be applied effectively in several situations including class III malocclusion, class II malocclusion, and facial asymmetry. However, debate on the SFA continues and many issues remain to be resolved. This review article addresses the current issues regarding the SFOA, including its advantages and disadvantages, as well as its indications and contraindications. The authors summarize various aspects of the SFA and expect that this review article will help surgeons and orthodontists better understand the current status of the SFA.

Enhancing the Orthognathic Surgery Experience: Treatment in 10 Weeks "Surgery First" Approach

This case report describes the successful treatment of a 25-year-old male with maxillary retrognathism, skeletal and dental Class III malocclusion, anterior and posterior crossbite, negative overjet and overbite, mild mandibular crowding, and lower midline deviation. The nonextraction treatment plan included: (1) maxillary and mandibular arch fixed appliance and (2) Le Fort 1 maxillary osteotomy and postsurgical orthodontic treatment. The orthodontic treatment was initiated with 0.022" preadjusted brackets bonded to all the teeth except the maxillary second molars, 2 days before the surgery without any archwires. Two weeks after the surgery, maxillary and mandibular arch alignment along with the occlusal adjustments was started with the use of 0.018" NiTi wires, in both arches. Optimum esthetic and functional results were achieved in 10 weeks after the surgery, with the cooperation of two specialties and the use of surgery first approach.

A Retrospective Cohort Study of 45 Cases Treated With Surgery First Approach in Orthognathic Surgery and a Short Review

Study Design

Retrospective cohort study.

Objective

The purpose of this study was to evaluate and share our experience with the surgery first approach (SFA) for correction of skeletal malocclusion.

Methods

After consultation with the department of orthodontics, 45 patients with skeletal malocclusions suitable to undergo SFA were enrolled in this study (14 bimaxillary protrusion and 31 skeletal class III malocclusion). Le Fort I maxillary osteotomy, bilateral sagittal split ramus osteotomy, subapical osteotomy, and genioplasty were performed as required. After a healing period of 2 weeks, postoperative orthodontic treatment was started to achieve the final occlusion.

Results

The mean duration of postoperative orthodontic treatment was 15.2 months, which is much shorter than the conventional orthodontic first approach (OFA) where presurgical orthodontic duration alone takes 12-24 months according to an individual. In the bimaxillary protrusion group, it was 18 months, which was significantly longer than for the other group (P < .05).

Conclusions

SFA offers an efficient alternative to conventional OFA with shorter total treatment duration, immediate marked improvement in facial profile, reduced biological costs, and similar operative stability. However, it comes at the cost of heightened challenges regarding case selection, accurate prediction, and surgical precision. With a joint venture between skilled and experienced surgeons and orthodontists, the outcome can be very promising.

Current status of surgery-first approach (part III): the use of 3D technology and the implication in obstructive sleep apnea

Considering psychosocial needs of patients, it is not surprising that surgery-first approach (SFA) is becoming more popular than ever. Although the concept of SFA was introduced a few decades ago, the limitation of analysis method based on two-dimensional images makes surgeons reluctant to choose SFA. Recently, the advancement of three-dimensional technology allows us to perform SFA even without minimal pre-surgical orthodontic treatment, and the prediction of surgical outcome became more accurate, especially in obstructive sleep apnea (OSA) patients to whom the advantages of SFA should be more significant. Here, we describe the current trend of SFA and its implication in OSA patients.

Retreatment of a patient: Orthognathic surgery-first approach with customized lingual appliances combined with miniplate anchorage

Orthognathic surgery is necessary when a patient's major complaints include skeletal discrepancies that cannot be corrected with orthodontic treatment alone. Currently, orthognathic surgery can be performed through conventional and surgery-first approaches. Some advantages are attributed to the surgery-first approach, such as shortened treatment time and immediate esthetic improvement. The aim of this case report is to present the retreatment of a patient presenting with a skeletal Class III malocclusion, with maxillary retrusion and mandibular protrusion, who was successfully treated with the surgery-first approach and customized lingual appliances, combined with miniplate anchorage in the postoperative orthodontic treatment. The total orthodontic treatment time was 8 months.

Surgery-First Approach in the Orthognathic Patient

The surgery-first approach (SFA) has become a recent alternative to the conventional 3-stage approach to orthognathic surgery. Skeletal anchorage in orthodontics has facilitated the resurgence of this treatment sequence. By eliminating the presurgical phase of orthodontic treatment, patients have immediate resolution to their facial deformity. Treatment duration has been shown to be reduced; the difference with the conventional approach being approximately 5 months. Patient satisfaction with this approach is very high as measured by quality-of-life surveys. This article describes the indications and step-by-step approach of this technique in conjunction with virtual surgical planning.

Orthodontic treatment time: can it be shortened?

INTRODUCTION

In the literature, no consensus has been reached about orthodontic treatment time. Similarly, the determining factors of the latter have not yet been completely elucidated.

OBJECTIVE

The aim of the present article was to deepen the discussion on the major factors influencing orthodontic treatment time, as well as to present some strategies that have proven effective in controlling and shortening it.

METHOD

Based on evidences found in the literature, the method focussed in providing the basis for clinical decision-making.

CONCLUSIONS

Treatment time varies according to the type of malocclusion and treatment options. Orthodontist's influence, patient's characteristics and compliance are all decisive in determining treatment time, while the effects provided by orthodontic appliances and methods used to speed tooth movement up seem little effective.

Bacteremia after micro-osteoperforation

OBJECTIVE

To find out the presence of bacteremia following micro-osteoperforation.

MATERIAL AND METHODS

The sample consisted of 28 Class I orthodontic patients (21 women, 7 men; mean age, 18.11±0.4 years). The micro-osteoperforation was performed 4 weeks following bonding of fixed orthodontic appliances. Using aseptic technique, 20-mL blood sample was collected before the micro-osteoperforation and another 20-mL, 60 seconds after the first micro-osteoperforation. The blood was inoculated into culture bottles and incubated at 37°C for 1 week. Bacterial growth was investigated by using Gram staining technique. The results were analysed using the McNemar test.

RESULT

No significant difference between the preoperative and postoperative samples was found with respect to bacteremia (P=0.229).

CONCLUSION

Micro-osteoperforation technique is not related to transitory bacteremia.

Surgery-first/early-orthognathic approach may yield poorer postoperative stability than conventional orthodontics-first approach: a systematic review and meta-analysis

OBJECTIVE

There are conflicting views on the postoperative stability of surgery-first and surgery-early approaches in orthognathic surgery. We systematically reviewed the literature to compare the difference in postoperative stability between a surgery-first/early orthognathic approach (SFEA) and a conventional orthodontics-first approach (COA).

STUDY DESIGN

PubMed, Embase, and Cochrane Library were searched for studies related to the postoperative stability of SFEA. The primary outcome was the horizontal relapse at the pogonion. Weighted mean differences with 95% confidence intervals were pooled using a random-effects model.

RESULTS

We analyzed 12 studies (total of 498 participants). The pooled estimate suggested that the SFEA group manifested less postoperative stability than COA group (weighted mean difference, 1.50; P < .00001), with moderate heterogeneity (I² = 53%). The result of subgroup analysis yielded no subgroup difference. Sensitivity analysis conducted by omitting one study at a time further validated the robustness of the result.

CONCLUSIONS

Based on the meta-analysis, the mandible tends to rotate counterclockwise more in the SFEA group, which indicate a poorer postoperative stability than in the COA group. Patient screening and treatment plans should be reviewed carefully to compensate for possible postoperative relapse when adopting SFEA.

Surgery First Orthognathic Approach Without Presurgical Orthodontic Treatment: Questions and Answers

"Surgery-First" for patients with malocclusion and skeletal disharmony is a new process of employing bony corrective surgery (first) without removal of dental compensations followed by orthodontic finishing (second). This process breaks with the time-tested principles of traditional orthognathic surgery. Not unexpectedly, there is slow adoption of this new process, particularly in the West. Ten frequently asked questions regarding Surgery First are asked and answered in this report in an attempt to provide an increased level of comfort for Plastic and Maxillofacial Surgeons in instituting this process in their practice.

Corrective outcome and transverse stability after orthognathic surgery using a surgery-first approach in mandibular prognathism with and without facial asymmetry

OBJECTIVES

The aim of this study was to evaluate corrective outcome and transverse stability after orthognathic surgery via a surgery-first approach (SFA) in mandibular prognathism with and without facial asymmetry using 3-dimensional analysis.

STUDY DESIGN

Twenty-nine patients who received mandibular setback surgery using SFA were divided into 2 groups according to the menton deviation (4 mm): symmetry group (n = 17) and asymmetry group (n = 12). Using computed tomography images obtained before (T0), immediately after (T1), and 6 months after (T2) surgery, time-dependent changes in variables related to facial asymmetry, including maxillary height, ramal length, frontal and lateral ramal inclination, mandibular body length, and mandibular body height, were evaluated.

RESULTS

Immediately after surgery, the asymmetry group showed significantly decreased discrepancies between the longer and non-longer sides for all variables (P < .05); there were no significant differences in discrepancies between the 2 groups. During the postoperative period, no significant changes in discrepancies were found in any variable in either group. Compared with T0, the asymmetry group showed significantly decreased discrepancies in ramal length, frontal and lateral ramal inclination, and mandibular body length at T2.

CONCLUSIONS

Variables related to facial asymmetry showed significant improvement after surgical-orthodontic treatment using SFA, and corrected outcomes showed good postoperative stability in both the symmetry and asymmetry groups.

Surgery-first: a new approach to orthognathic surgery

This case study describes the treatment of a 20-year-old white woman with a skeletal Class III and dental Class III malocclusion followed by a retrognathic and contracted maxilla, light mandibular crowding and a median line deviation of 5 mm. The treatment was based on the Surgery-First approach, involving LeFort I maxillary advancement surgery, and it was followed by orthodontic treatment. During the 6-month treatment period, excellent aesthetic results and good functional occlusion were achieved.

Postoperative changes in mandibular position after mandibular setback surgery via the surgery-first approach in relation to the increase of vertical dimension and the amount of mandibular setback

OBJECTIVES

This study aimed to compare preoperatively predicted rotational relapse with actual post-treatment mandibular position after mandibular setback surgery via the surgery-first approach and to evaluate the effect of the increase of vertical dimension (VD) on surgical occlusion and the amount of mandibular setback on postoperative mandibular positional changes.

STUDY DESIGN

Twenty-nine patients who underwent bilateral sagittal split ramus osteotomy for mandibular prognathism were evaluated by using lateral cephalograms, which had been obtained preoperatively, immediately postoperatively, and immediately after debonding. Increase of VD on surgical occlusion was measured preoperatively. We estimated the mandibular forward movement resulting from the postoperative mandibular anticlockwise rotation during postoperative orthodontic treatment and compared it with the actual post-treatment mandibular position.

RESULTS

The actual postoperative mandibular forward movement (2.1 mm) was significantly greater compared with the forward movement (1 mm) predicted preoperatively (P < .01). The postoperative mandibular forward movement was greater in the groups with greater VD increase (>1.5 mm) or greater mandibular setback (>10 mm), even though there was no statistically significant difference.

CONCLUSIONS

These results suggest that additional postoperative relapse may occur with mandibular rotational relapse, and VD increase and the amount of mandibular setback may affect post-treatment mandibular position in surgery-first orthodontic treatment.