The surgery-first approach for orthognathic correction of maxillary deficiency-is it stable? Three-dimensional assessment of CBCT scans and digital dental models.

The aim of this study was to determine the skeletal stability of Le Fort I maxillary advancement following the surgery-first approach, by three-dimensional (3D) assessment of cone beam computed tomography (CBCT) scans and digital dental models. CBCT scans of 25 class III patients obtained 1 week preoperatively (T0) and 1 week (T1) and 6 months (T2) postoperatively were superimposed to measure surgical movements (T0-T1) and skeletal relapse (T1-T2). The distorted dentition of the CBCT scans at T1 was replaced with 3D images of the dental models to assess the postoperative occlusion. Surgical movements of the maxilla (mean ± standard deviation values) were 6.79 ± 2.30 mm advancement, 1.28 ± 1.09 mm vertically, and 0.71 ± 0.79 mm mediolaterally. Horizontal rotation (yaw) was 1.56° ± 1.21°, vertical rotation (pitch) 1.86° ± 1.88°, and tilting (roll) 1.63° ± 1.54°. At T2, the posterior relapse was 0.72 ± 0.43 mm (P = 0.001) and relapse in pitch was 1.56° ± 1.42° (P = 0.007). There was no correlation between the size of the surgical movements and the amount of relapse. A weak correlation was noted between the number of teeth in occlusal contact immediately following surgery and relapse of maxillary roll (r = - 0.434, P = 0.030). The stability of maxillary advancement with the surgery-first approach was satisfactory and was not correlated with the quality of the immediate postoperative occlusion.

The Skeletal Stability of Combined Surgery First Approach and Clear Aligners in Skeletal Class III Malocclusion Correction: A Randomized Controlled Trial.

The surgery first approach (SFA) and clear aligners technique can address traditional treatment defects, such as prolonged waiting times for surgery and a less desirable facial appearance due to wire aligners. However, the curative effect of the combination remains uncertain. The randomized controlled study aimed to evaluate the skeletal stability of the SFA compared to the conventional orthodontic first approach (OFA), both of which were applied with clear aligners. A total of 74 participants were randomly allocated to two groups: the SFA group (experimental) and the OFA group (control). The skeletal deviation was calculated using reconstruction models from computed tomography scans taken immediately and 6 months after surgery. The largest median deviations were detected in the y-axis of the mandible for both two groups, separately 1.36 mm in the experimental group and 1.19 mm in the control group. Apart from the maxillary yaw dimension (p = 0.005), there were no significant differences between the two groups in terms of linear and angular deviation. The experimental group had an overall treatment time of 18.05 ± 2.53 months, while the control group took 22.83 ± 3.60 months (p < 0.05). Therefore, the combined surgery-first and clear aligners treatment can achieve comparable skeletal stability to the conventional approach, while also saving significant time.

Effect of surgery-first approach on quality of life and mental health of orthognathic patients: A systematic review and meta-analysis.

Objectives: This study intends to explore the effects of the surgery-first approach (SFA) on quality of life and mental health of patients who undergo orthognathic surgery compared to the conventional three-stage approach (CTA). Data: The analysis included eight studies with a total of 307 patients, of which one was randomized controlled trial (RCT), one was clinical controlled trial (CCT), and six were non-randomized studies of interventions (NRSIs). Sources: Electronic databases such as Medline, Embase, Scopus, and Web of Science were searched for eligible trials up to April 2023. Study selection: RCTs, CCTs, and NRSIs, which compared the quality of life or mental health of orthognathic patients treated with SFA and CTA, were included in this study. The meta-analysis showed that the standardized mean differences (SMD) of Oral Health Impact Profiles-14 (OHIP-14) scores and the Orthognathic Quality of Life Questionnaire (OQLQ) between SFA and CTA were -1.58 (P = 0.05) and -2.99 (P < 0.00001) at the termination of the first-stage treatment, which altered to -0.94 (P = 0.54) and 0.09 (P = 0.65) after total treatment. Two studies applied the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) and the Beck Depression Inventory (BDI-II) to examine mental health, resulting in a trend similar to the former scales. Conclusion: In contrast to the conventional procedure, orthognathic treatment with SFA can instantly enhance the quality of life at the end of the first-stage treatment but has similar effects after the overall treatment. Moreover, SFA has a positive impact on psychological conditions. Clinical significance: This study first systematically reviewed the effect of SFA on patients' mental well-being. According to our findings, it is better to select SFA if possible. Otherwise, the patient's psychological condition should be monitored appropriately throughout decompensation for better well-being both physically and mentally.

Surgery-first in interdisciplinary class II cases.

OBJECTIVES: To present an interdisciplinary case treated with a surgery-first orthognathic approach, followed by orthodontic and prosthodontic treatment. CLINICAL CONSIDERATIONS: After an accurate pre-operative virtual planning, a young patient with skeletal class II, retrognathia, and an anterior open bite was treated with bimaxillary orthognathic surgery without pre-surgical orthodontic decompensation. Orthodontic treatment was carried out post-operatively. The treatment was completed with a prosthodontic phase to improve the final esthetic outcome of the smile. CONCLUSIONS: A surgery-first approach allowed to achieve esthetic and functional results in a reduced treatment duration that remained stable over the course of 1 year. The outcomes were consistent with prior research in terms of advantages brought by following an accurately planned surgery-first protocol. Nevertheless, longer-term follow-up was required to evaluate the treatment stability. CLINICAL SIGNIFICANCE: An accurately planned surgery-first approach significantly helped in shortening the duration of the treatment, while providing a stable, functional, and esthetic solution to the patient's problems.

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.

Surgery first with clear aligners for a Class II patient: Case report and literature review.

Orthognathic surgery has undergone multiple modifications in timing approaches, among them, surgery first represents an approach that potentially reduces length of time and shows earlier results in facial changes, nevertheless, it has been used mostly to treat Class III skeletal anomalies. Also, fixed appliances orthodontics is the most common choice, however, recent literature shows clear aligners can achieve the same results. This paper presents a case of a 20-year-old female with a skeletal Class II treated with surgery first and clear aligners protocol, with a literature review of surgery first in Class II patients; evidencing that this approach can be suitable to achieve satisfactory and stable results, although larger patient samples are needed.

Management of Short Face Syndrome with Masseter Muscle Hypertrophy: A Surgery-First Approach.

Short face syndrome (SFS) is a condition with a clinical impression of deficient lower anterior facial height, which is an esthetic disharmony based on vertical facial proportions rather than absolute dimensions. Masseter hypertrophy is one of the etiologic factors in which there is an enlargement of unilateral or bilateral masseter muscles. Clinically, it presents as a quadrangular face characterized by bulging of the mandibular angle giving a muscular appearance. Despite the muscular origin, surgery should be aimed toward bony reduction (osteoplasty) followed by supplemented myotomy. This case report addresses one such case of SFS treated with surgery-first approach and supplemented myotomy with a 1-year follow-up. The esthetic facial profile, pleasant smile and overall good treatment outcome remained stable 1 year after orthognathic surgery and orthodontic treatment.

Improvement in facial aesthetics of orthognathic patients after surgery-first approach.

Facial appearance significantly affects psychosocial wellbeing, and an improvement in facial aesthetics is considered an essential outcome of orthognathic treatment. The surgery-first approach (SFA) has emerged as a promising alternative to the conventional orthodontics-first approach (OFA) due to its potential advantages in reducing treatment duration and cost, delivering early aesthetic improvement, and increasing patient satisfaction. However, its impact on final facial aesthetics and how it compares with the OFA has, to our knowledge, not yet been investigated. This retrospective study aimed to compare the improvement in facial aesthetics after orthognathic surgery in an SFA and an OFA group. Preoperative and postoperative 3-dimensional stereophotogrammetry facial images of 40 patients were evaluated by five professional assessors using the Global Aesthetic Improvement Scale (GAIS). Similar aesthetic improvement outcomes were found in both the SFA and OFA groups. The GAIS score significantly correlated with the following facial variables: upper lip projection, chin prominence, facial proportions, paranasal hollowing, lip competence, mandibular projection, and facial profile. No significant correlation was found between a change in aesthetic score and the surgical variables. There was a positive association between overall GAIS score and the gender and experience level of the individual assessors. This study suggests that aesthetic facial improvement achieved with the SFA is satisfactory and comparable to that of the OFA.

Dental Occlusion Characteristics for Treatment Decision-Making Regarding Surgery-First Approach in Orthodontics.

The surgery-first approach (SFA) is conducted to decrease the difficulty and duration of orthodontic treatment by correcting the skeletal discrepancy at the initial stage of treatment. However, the indication of the SFA has not been well defined yet. This study explored the dental occlusion characteristics for treatment decision-making regarding the SFA. A total of 200 skeletal Class III patients were consecutively collected and divided into two groups: the orthodontic-first approach (OFA) group and the SFA group. The pretreatment digital dental models and lateral cephalograms were measured. Logistic regression was completed and receiver operating characteristic (ROC) curves were obtained to predict the probability of the SFA. Results showed that the ROC model with L1-MP, upper and lower arch length discrepancy, overbite, and asymmetric tooth number as influencing factors revealed that the sensitivity and specificity for determining SFA were 83.0% and 65.0%, respectively; the accuracy of prediction was 75.0%. In conclusion, our findings indicate that the six measurements from digital dental models and lateral cephalograms can be effectively applied in treatment decision-making for the SFA with satisfactory accuracy.

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.

Orthognathic surgery and aligners. A comparative assessment of periodontal health and quality of life in postsurgical orthodontic treatment with aligners versus traditional fixed appliances: a randomized controlled trial

Background: Removable clear aligners have become very popular in the last few decades, but they are still little used in the field of orthognathic surgery (OS). The objective of this study was to compare periodontal health and quality of life (QoL) associated to postsurgical orthodontic treatment. Material and methods: Patients with dentofacial deformities undergoing OS were randomly allocated to receive postsurgical orthodontic treatment with either fixed orthodontic appliances or Invisalign. The main outcomes were periodontal health and QoL. Plaque index, probing depth and bleeding on probing were assessed as periodontal health indicators. QoL was assessed through the Orthognathic Quality of Life Questionnaire (OQLQ-22) and the Oral Health Impact Profile (OHIP-14). Data were analyzed before surgery and end of treatment. Total duration of treatment was also recorded. Results: Twenty-eight patients were randomized, (16 women, 12 men). Periodontal assessment showed better outcomes for the Invisalign group: bleeding on probing (p=0.013), plaque index (p=0.001) and probing depth (p<0.001). The QoL questionnaires showed significant differences in favor of the Invisalign group: OHIP-14 (p=0.004) and OQLQ-22 (p=0.002). Total duration of treatment was similar in both groups (p=0.575). Conclusions: Compared to traditional orthodontics with fixed appliances, patients managed with clear aligners after OS (surgery-first approach) had better periodontal health and QoL outcomes. (AU)

Surgery-First Approach for Dentofacial Deformity: A Systematic Review.

This review is based on the surgery-first approach for dentofacial deformity. This review has critically highlighted various promising aspects and factors associated with dentofacial deformity and can be viewed as valuable research work. In addition, this review highlights a systematic manner of surgery that can reduce the possible duration of treatment. The main findings of the review have established that the appropriate approaches to surgery can be beneficial for patients of any age group. The surgery-first approach is mainly utilized for tissue transfer as well as oral cancer as the first-line treatment. This critical review has successfully evaluated the limitations and advantageous traits of the specific surgery approach that has been outlined in this context. It has established the surgery approach as an effective measurement to reduce the time taken for treatment without compromising the patient's health. In the final phase of this review, the accuracy and appropriateness of this surgery-first approach have been effectively demonstrated.

Orthognathic Surgery to Enhance the Smile.

An esthetic smile is an integral feature of beauty. Improvement of the smile can be achieved by a combination of orthognathic surgery, orthodontics, and cosmetic dentistry. Preoperative evaluation serves to address a patient's surgical goals; it allows a surgeon to perform a detailed facial analysis and identify patients who are contraindicated for surgery. LeFort I and bilateral sagittal split osteotomy are performed to minimize the risk of complications. Injuries to the inferior alveolar nerve are the most common complication after orthognathic surgery, in which 90% of patients experience transient sensory disturbance of the lower lip in the postoperative period.

Surgery First and Surgery Early Treatment Approach in Orthognathic Surgery.

We have observed a revival of the original Surgery First approach in orthognathic surgery. Fully digital planning and simulation of the surgery has improved the predictability of Surgery First procedures. The orthodontist plays a crucial role in the successful management of Surgery First and Surgery Early cases. Surgery First and Surgery Early procedures have made the correction of a dentofacial deformity and dysgnathia a clear and transparent procedure. The decision of the treatment protocol is based on a thorough consideration and discussion between the surgeon, the orthodontist, and the patient for a successful outcome.

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.

Surgery-First Approach; from Claims to Evidence: A Comprehensive Review.

The main goals of treatment of dentofacial deformities are to achieve optimal esthetics and ideal functional occlusion. The conventional orthognathic surgical approach includes a long presurgical orthodontic phase, which takes about 18 months. During this phase, the patients' appearance is deteriorated and their motivation to continue treatment significantly decreases. In the surgery first approach (SFA), orthognathic surgery is performed prior to orthodontic treatment, and orthodontic treatment is performed postoperatively to improve dental occlusion and for final settling. The SFA has two main advantages namely shortening of treatment period, and early improvement of the appearance of patient. The SFA has significant advantages especially for class III patients. This study aimed to review the available articles on this topic published from 2012 to 2019 to achieve a comprehensive understanding of different aspects of the SFA. The databases were searched by two researchers and a total of 11 eligible articles were selected for study inclusion. The results were categorized into two categories of stability of the results of the SFA, and duration of treatment, in comparison with the conventional approach. Although different aspects of the SFA have been previously evaluated by dental clinicians, a considerable gap of information still exists regarding the details of this approach, which calls for further research in this respect.

Surgery-first approach for correction of class III dentofacial deformity with Le Fort I osteotomy; is it advantageous?

The surgery-first approach (SFA) to orthognathic treatment aims to reduce its duration without compromising the outcome. However, the objective assessment of the achieved occlusion has been limited. This study was designed to assess the treatment duration, outpatient appointment number, and quality of occlusal outcomes for two groups of patients; one treated with the SFA and the other with an orthodontics-first approach (OFA). We carried our a retrospective cohort study of case records for twenty consecutive SFA, and 23 consecutive OFA, cases with class III malocclusions, treated with Le Fort I maxillary osteotomy only. Pre-and post-treatment study models were assessed using the Peer Assessment Rating (PAR). Significant differences (p<0.001) were found between the median active treatment durations (10.2 months for the SFA and 32.5 months for the OFA) and appointment numbers (14 for SFA and 24 for OFA). Median absolute PAR reductions were 40 for the SFA and 39 for the OFA. There was no significant difference between the groups regarding quality of occlusal correction. Treatment durations for the SFA group were significantly shorter than for the OFA group, with fewer outpatient appointments. The quality of occlusal outcome for both SFA and OFA groups were satisfactory and comparable.

Comparison of short-term condylar positional changes in mandibular prognathism after surgery-first approach: Symmetric setback versus asymmetric setback.

The aim of this study was to compare how the displacement of the mandibular condyle changed after symmetric or asymmetric mandibular setback surgery using the surgery-first approach (SFA). Patients who underwent mandibular setback surgery using the SFA were selected and divided into a symmetry group (n = 18) with differences of less than 2 mm between the right and left setback, and an asymmetry group (n = 18) with a difference of greater than 2 mm. Cone-beam computed tomography (CBCT)-generated cephalograms were obtained after three-dimensional superimposition of CBCT images taken before surgery (T0), within one week after surgery (T1), and seven months after surgery (T2). The condylar positions were measured. Condylar positional changes according to time were compared between the two groups and correlation analysis was performed. There were significant positional changes in mandibular condyles over time in both groups. However, most of these changes returned to their initial state. In the asymmetry group, there was a greater internal rotation of the mandibular condyle on the lesser setback side. The correlation analysis results revealed that only the setback difference was associated with rotational displacement of the condyle on the lesser setback side at two time points (T1-T0, T2-T0). In the SFA, significant condylar displacement occurred immediately after both symmetric and asymmetric mandibular setback surgery, and the right/left difference in mandibular setback showed a significant positive correlation with rotational displacement. Although more significant rotational displacement of the mandibular condyle was observed after asymmetric mandibular setback surgery, the amount was not large enough to be clinically significant.

Surgery-first treatment of a skeletal Class III malocclusion with a completely digital workflow.

Completely digital design/completely digital manufacturing (CDD/CDM) workflows have been widely used in orthodontic and orthognathic treatments. This case report introduces a CDD/CDM workflow consisting of clear aligners and virtual planning for a surgery-first approach (SFA) in a patient with a skeletal Class III malocclusion. Following a shortened treatment time of 5 months, the patient's facial appearance improved significantly, and well-balanced occlusion was obtained. SFAs with clear aligners can enable patients to achieve complete esthetic satisfaction during the therapeutic period. The CDD/CDM workflow provided accurate results, improved the clinical outcome, and reduced treatment time.

Comprehensive virtual orthognathic planning concept in surgery-first patients.

The surgery-first concept is becoming increasingly popular in orthognathic surgery since it offers major advantages such as a reduction of treatment duration and an increase in patient satisfaction by eliminating phases of presurgical orthodontic decompensation. Here, we present a novel interdisciplinary pathway of a fully virtual orthodontic-surgical planning concept in a surgery-first setting using a 3D-printed cutting guide and a customised maxillary implant for the Le Fort I osteotomy as well as a CAD/CAM-based stereolithographic final splint. Patient data from cone-beam computed tomography of the skull and a full arch dental scan were processed using the OnyxCeph3TM software (Image Instruments). A mutual computer-aided surgical simulation was conducted by the orthodontist and the oral and maxillofacial surgeon to determine the three-dimensional maxillary and mandibular movements. In a separate virtual planning session, the surgeon designed a customised maxillary guide and implant for precise intraoperative transfer (Geomagic Freeform Plus software, 3DSystems). A 3D-printed CAD/CAM-based final splint was fabricated by the orthodontist and used for accurate mandibular repositioning. We established a comprehensive virtual interdisciplinary orthognathic workflow and successfully applied this concept with a high level of accuracy in a series of surgery-first patients with different types of dentofacial anomalies. This novel fully computer-based pathway offers a high potential to improve the outcomes of orthognathic surgery and reduce total treatment time in the management of the orthognathic patient.