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Clinical Paper

Orthognathic Surgery

Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxxhttp://dx.doi.org/10.1016/j.ijom.2014.02.007, available online at http://www.sciencedirect.com

On a definition of theappropriate timing for surgicalintervention in orthognathicsurgeryF. Hernandez-Alfaro, R. Guijarro-Martınez: On a definition of the appropriatetiming for surgical intervention in orthognathic surgery. Int. J. Oral Maxillofac. Surg.2014; xxx: xxx–xxx. # 2014 International Association of Oral and MaxillofacialSurgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Together with the introduction of new orthodontic techniques andminimally invasive surgery protocols, the emergence of modern patient prototypeshas given way to novel timing schemes for the handling of dento-maxillofacialdeformities. The aim of this study was to define, justify, and systematize theappropriate timing for orthognathic surgery. A retrospective analysis oforthognathic surgery procedures carried out over a 3-year period was performed.Six timing schemes were defined: ‘surgery first’, ‘surgery early’, ‘surgery late’,‘surgery last’, ‘surgery only’, and ‘surgery never’. Gender, age at surgery, mainmotivation for treatment, orthodontic treatment length, and number of orthodonticappointments were evaluated. A total of 362 orthognathic procedures wereevaluated. The most common approach was ‘surgery late’. While aestheticimprovement was the leading treatment motivation in ‘surgery first’, ‘surgeryearly’, and ‘surgery last’ cases, occlusal optimization was the chief aim of ‘surgerylate’. Sleep-disordered breathing was the main indication for treatment in ‘surgeryonly’. Compared to ‘surgery late’, orthodontic treatment was substantially shorter in‘surgery early’ and ‘surgery first’ cases, but the number of orthodontic appointmentswas similar. In conclusion, the skilful management of dento-maxillofacialdeformities requires a comprehensive analysis of patient-, orthodontist-, andsurgeon-specific variables. Each timing approach has well-defined indications,treatment planning considerations, and orthodontic and surgical peculiarities.

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0901-5027/000001+010 $36.00/0 # 2014 International Association of Oral and Maxillofacial Surge

F. Hernandez-Alfaro1,2,R. Guijarro-Martınez1,2

1Institute of Maxillofacial Surgery, TeknonMedical Centre Barcelona, Barcelona, Spain;2Department of Oral and MaxillofacialSurgery, Universitat Internacional deCatalunya, Sant Cugat del Valles, Barcelona,Spain

Keywords: orthognathic surgery; timing; sur-gery first; dentofacial anomalies; malocclusion.

Accepted for publication 17 February 2014

During the last decade, treatment conceptsin orthognathic surgery have undergone aprofound reassessment. In particular, thetraditional therapeutic scheme based on avariable length of preoperative orthodonticpreparation, surgery itself, and a relativelystable period of postoperative orthodontics,

has given way to a new trend in surgicaltiming that entails the performance of thesurgical intervention prior to orthodontictreatment.1–7 The so-called ‘surgery first’approach has gained popularity amongorthodontists and surgeons for several rea-sons. First, the skeletal bases – and there-

fore the aesthetic concern, which is oftenthe patient’s chief complaint – are correctedfrom the beginning.1,6 This circumstanceimproves patient compliance with post-operative orthodontics and makes a power-ful contribution to global satisfaction withtreatment.5 Second, orthodontic treatment

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ons. Published by Elsevier Ltd. All rights reserved.

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Fig. 1. Case example 1: Frontal, three-quarter, and profile views of a patient treated with a‘surgery first’ approach. The patient’s main motivation for surgery was her wish to correct herfacial asymmetry and concave profile.

– and hence total treatment time – is sig-nificantly reduced. This improved ortho-dontic efficiency is probably related to thetransient demineralization of the operatedbones due to the regional acceleratory phe-nomenon (RAP)1,2,7–11 and to a more effi-cient skeletal position in which soft tissueimbalances that can interfere with ortho-dontic movements have been suppressed.7

Third, when compared to the conventionalorthodontics–surgery–orthodonticsapproach, a ‘surgery first’ protocol does notseem to impair the final occlusal result.Consequently, the satisfaction of orthodon-tists and patients with the treatment is atleast as high as with the traditional timingscheme.5

The ‘surgery first’ concept was imple-mented at our centre in 2010. After doc-umenting our preliminary experience withthis approach,1,5 we realized that a sig-nificant number of patients did not fall intothis ‘black or white’ (traditional approachvs. ‘surgery first’ approach) classification.Indeed, several patients were operated onat different time-points along the ortho-dontic treatment timeline. After a compre-hensive analysis of the indications andlimitations of these different timingschemes, the aim of this study was todefine, justify, and subsequently system-atize the appropriate timing for surgicalintervention in the context of dento-max-illofacial deformities.

Materials and methods

A retrospective analysis of all orthog-nathic surgery procedures performed ata specialized centre in dento-maxillofacialanomalies during a 3-year time period(June 2010 to June 2013) was performed.

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Fig. 2. Case example 1: Frontal, three-quarter,

The guidelines of the Declaration of Hel-sinki on medical protocol and ethics werefollowed in all treatment phases. Patientclinical records and media files werereviewed with the approval of the institu-tional medical centre committee on ethicalmedical practice.

Patients were classified according to thetime at which the surgical interventiontook place with regards to orthodontictreatment. The categories were establishedas outlined below.

Surgery first

By definition, this approach proceeds withorthognathic surgery without preoperativeorthodontic preparation and is followed byregular postoperative dental alignment.Our particular methodology has beendescribed in detail elsewhere.5

Patients were selected for a ‘surgeryfirst’ sequence on the basis of a skeletalmalocclusion requiring combinedorthodontic–surgical treatment withoutextractions, the need for aesthetic

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and profile views after surgery.

improvement, or sleep-disorderedbreathing (SDB) as the main motivationfor treatment. Orthodontic managementwas performed by an officially qualifiedorthodontist with previous experience inorthognathic surgery. Exclusion criteriawere as follows: severe crowding in needof extractions, severe asymmetry withthree-dimensional (3D) dental compen-sations, transverse maxillary hypoplasiarequiring previous surgically-assistedrapid palatal expansion (SARPE), classII second division with overbite, acuteperiodontal problems, and underlyingtemporomandibular joint (TMJ) disease(Figs 1 and 2).

As well as routine virtual planning ofthe orthognathic osteotomies, the neces-sary dental movements of the future ortho-dontic treatment were simulated in a 3Dvirtual orthodontic setup for this group ofpatients. This was built by the combinedorthodontic–surgical team (Fig. 3).

Brackets (without archwires) werebonded 1 week before surgery. In orderto avoid dental movements that could

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Fig. 3. Case example 1: Simulation of skeletal movements and virtual orthodontic setup.Bimaxillary surgery with 6-mm maxillary advancement, mandibular midline correction, andmandibular front-block osteotomy for incisor decompensation were planned.

Fig. 4. Case example 1: Execution of buccalinterdental corticotomies in the mandibularfront-block segment in order to acceleratepostoperative orthodontic movement. Trans-mucosal 2.0-mm miniscrews were used tostabilize the occlusion. These were placedbetween the first and second bicuspids.

Fig. 5. Case example 1: Preoperative occlu-sion (top) and postoperative occlusion at 32weeks after orthodontic treatment (bottom).

Fig. 6. Case example 2: Frontal, three-quarter, and profile views of a patient treated with a‘surgery late’ approach. The patient’s main motivation for surgery was aesthetics (correction offacial asymmetry). However, a ‘surgery late’ approach was preferred based on the presence ofanterior crowding and three-dimensional compensations.

render the computer assisted design–com-puter assisted manufacturing (CAD–CAM) splint inaccurate and thus interferewith proper bone positioning, the first softarchwire was not placed until 24 h beforesurgery or even until the first postoperativeorthodontic appointment at 1–2 weeksafter surgery.

In addition to the standard maxillaryand mandibular osteotomies, interdentalcorticotomies were systematically exe-cuted with a piezoelectric microsaw inorder to accelerate postoperative ortho-dontic movement owing to the RAP9,11–

13 (Fig. 4). These corticotomies wereextended through the entire thickness ofthe buccal cortical layer and interruptedwhen penetrating the medullary bone. Noluxation manoeuvres followed. Wheneverthe targeted teeth were not accessiblethrough the incision required for theorthognathic procedure itself, a tunnelapproach under endoscopic assistancewas used. This tunnel approach was per-formed through one to three buccal ver-tical incisions (5–10 mm) per arch in orderto minimize soft tissue debridement andperiodontal risks. The technical details ofthis particular method are available else-where.13

Orthodontic treatment began at the endof the second postoperative week in orderto benefit from the RAP. Archwires werechanged every second to third week. Dur-ing the first postoperative month, intrao-peratively placed miniscrews were usedfor skeletal anchorage, thereby avoidingpremature loading of the orthodonticappliances and undesirable dental extru-sions5 (Fig. 5).

Surgery early

Patients were selected for a ‘surgery early’approach when the aforementioned selec-tion criteria for ‘surgery first’ were notcompletely met, despite the patient’s wish

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for an immediate aesthetic change. Withthis treatment concept, the presence ofsevere crowding in need of extractionsand complex 3D dental compensationsdue to facial asymmetry, including dentalmidline deviation, required at least partialorthodontic preparation. As soon as thesevere crowding had been managed withextractions and a good amount of thenecessary space closure was achieved,surgery was performed. In the case ofsevere 3D compensations and/or dentalmidline deviations, surgery proceededonce transverse compensations wereresolved.

Regarding treatment planning, the sur-gery itself, and the postoperative ortho-dontic treatment, the same methodologyas for ‘surgery first’ was followed. In otherwords, virtual planning included bothosteotomy simulation and 3D orthodonticsetup. Intraoperatively, the regular facialosteotomies were followed by interdentalcorticotomies in order to further enhancethe RAP, and miniscrews were placed forintraoperative intermaxillary fixation andpostoperative orthodontic use; orthodontictreatment began after 2 postoperativeweeks.

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Surgery late

The ‘surgery late’ category corresponds tothe conventional approach for orthog-nathic surgery, i.e., the traditionalsequence of preoperative orthodontics,surgery, and postoperative orthodontics.

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Fig. 7. Case example 2: Frontal, three-quarter, and profile views at the end of treatment.

Fig. 8. Case example 2: Virtual treatment planning. Bimaxillary surgery with maxillary cantingcorrection, mandibular canting and midline correction, and advancement and anticlockwiserotation of the maxillomandibular complex was planned.

Fig. 9. Case example 2: Preoperative occlusion (top) and postoperative occlusion at 91 weeksafter orthodontic treatment (bottom).

Patients were selected for this approachwhen the conditions for a ‘surgery first’ or‘surgery early’ timing scheme were notmet, or when the patient’s main motiva-tion for treatment was the achievement ofoptimal occlusal parameters (Figs 6–9).

Patients underwent routine preoperativeorthodontic preparation for arch levellingand decompensation. Surgery proceededin a standard fashion. As opposed to the‘surgery first’ and ‘surgery early’ proto-cols, the use of miniscrews or other tem-porary anchorage devices (TADs) was not

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systematic but rather reserved for cases ofmaxillary segmentation. Likewise, corti-cotomies were not performed routinely.

Surgery last

The ‘surgery last’ timing group comprisedpatients who had undergone compensa-tory orthodontic treatment in the pastbut had eventually decided upon surgery.In these cases, a compensated, stableocclusion was already present, such thatno additional orthodontic preparation was

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necessary (Figs 10 and 11). Cases whopresented an inappropriate occlusion andrequired further preoperative tooth align-ment or who accepted a new decompen-sating orthodontic treatment withreopening of extraction spaces wereexcluded from immediate surgery andmanaged with a ‘surgery early’ or ‘surgerylate’ treatment concept.

Since these patients presented a func-tional class I occlusion, surgical planningwas aimed at improving the aesthetic para-meters maintaining, nevertheless, the pre-operative maxillomandibular relationship.In other words, bimaxillary surgery withclockwise or counter-clockwise rotationwas the main surgical movement. In somecases, the occlusal relationship wasslightly modified in order to achieveocclusal optimization in addition to aes-thetic improvement (Figs 12 and 13). Nocorticotomies were executed, since nomajor dental movements would follow.Miniscrews were placed for intraoperativeintermaxillary fixation and postoperativeelastic mechanics.

Surgery only

Conceptually, a ‘surgery only’ protocolproceeds directly with surgery, withoutany previous or subsequent orthodontictreatment. This approach was limited tothree specific indications: (1) patients withan exclusively aesthetic concern who pre-sented a stable postoperative occlusion asconfirmed by study models; (2) patientswith total or subtotal edentulism in whomorthodontic treatment would add little orno benefit to the final outcome, and inwhom a combined prosthodontic–surgical(orthognathic surgery plus implant place-ment) management was foreseen; (3)patients with obstructive sleep apnoea(OSA) and a stable occlusion in whomthe therapeutic objective was entirelyfunctional (respiratory), and who refusedto undergo any orthodontic treatment(Figs 14 and 15).

As in the ‘surgery last’ category, surgi-cal planning required that the preoperativeocclusion be maintained. Anticlockwiserotation of the maxillomandibular com-plex was the most common surgical move-ment in order to increase the upper airwayvolume (Fig. 16). Miniscrews were placedin all cases. No corticotomies were per-formed.

Surgery never

Conceptually, this group comprisespatients who never undergo orthognathicsurgery, in other words, patients with

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Fig. 10. Case example 3: Frontal, three-quarter, and profile views of a patient treated with a‘surgery last’ approach. The patient had undergone compensatory orthodontic treatment in thepast, resulting in a stable occlusion but an unsatisfactory aesthetic outcome.

Fig. 11. Case example 3: Frontal, three-quarter, and profile views after surgery.

Fig. 12. Case example 3: Virtual treatment planning. Bimaxillary surgery with anticlockwiserotation and advancement of the maxillomandibular complex was planned.

Fig. 13. Case example 3: Preoperative occlu-sion (top) and postoperative occlusion (bot-tom).

Table 1. Results.

Approach ‘Surgery first’ ‘Surgery early’ ‘Surg

Total number of patients 68 15 261

Percentage out of total (N = 362) 18.8% 4.1% 72.1%Males 27 7 110

Females 41 8 151

Mean age at the time of surgery, years 25.5 28.2 21.8

Age range at the time of surgery, years 19–46 17–38 16–68Motivation for treatment

Aesthetic concern 63 14 115

Occlusal concern 0 1 146

SDB 5 0 0

Most common surgical procedure Bimaxillarysurgery

Bimaxillarysurgery

Bimaxsurger

Mean duration of orthodontic treatment, weeks 45.3 59.5 97.5

Mean number of orthodontic appointments 21 28 29

SDB, sleep-disordered breathing.

documented dentoskeletal deformitieswho have a wholly occlusal concernand/or fear of surgery leading them toseek exclusive orthodontic treatment.

For all six timing categories, the follow-ing variables were recorded: gender, age atthe time of surgery, chief complaint andmain motivation for treatment, orthodon-tic treatment length, and number of ortho-dontic appointments.

Results

From June 2010 to June 2013, a totalnumber of 362 orthognathic procedureswere performed at our centre (in 150males and 212 females, mean age 23.4years).

Results are summarized in Table 1. Themost commonly indicated approach wasby far ‘surgery late’, i.e., the traditionaltiming modality. No patients wereassigned to the ‘surgery never’ category;as a unit specializing in orthognathic sur-gery, no exclusively orthodontic cases aremanaged at this centre.

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ery late’ ‘Surgery last’ ‘Surgery only’

11 7 3.0% 1.9%

3 38 435.7 39

24–52 33–57

11 30 00 4

illaryy

Bimaxillarysurgery

Bimaxillarysurgery

– –– –

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Fig. 14. Case example 4: Frontal, three-quarter, and profile views of a patient with obstructivesleep apnoea (OSA) treated with a ‘surgery only’ approach.

Fig. 15. Case example 4: Frontal, three-quarter, and profile views after surgery.

Fig. 16. Case example 4: Preoperative (left) and postoperative (right) three-dimensionalreconstruction of the upper airway. A significant volumetric increase in the airway was achievedwith counter-clockwise rotation and advancement of the maxillomandibular complex, whilemaintaining the preoperative occlusion.

Candidates for the ‘surgery last’ or‘surgery only’ approaches tended to beolder than patients undergoing a ‘surgeryfirst’, ‘surgery early’, or ‘surgery late’treatment scheme. In all cases, bimaxillarysurgery was the most common surgicalprocedure.

With the ‘surgery first’, ‘surgery early’,and ‘surgery last’ approaches, the mostcommon motivation for treatment wasthe desire for an improvement in facialaesthetics. Alternatively, occlusal optimi-zation was the chief objective of patientsselected for a ‘surgery late’ approach.Finally, patients who underwent a ‘surgeryonly’ scheme sought functional improve-

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ment of their SDB, followed closely byaesthetic improvement.

Compared to the ‘surgery early’ and‘surgery first’ timing modalities, ‘surgerylate’ required an average of 38 weeks and52.2 weeks more of orthodontic treatment,respectively. Nevertheless, the total num-ber of orthodontic appointments was simi-lar for the three timing options: 21 for‘surgery first’, 28 for ‘surgery early’, and29 for ‘surgery late’.

Discussion

The orthodontic and surgical communitiesof the last 50 years have witnessed a

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prodigious revolution in the treatment ofdento-maxillofacial deformities. In thesurgical field, improved rigid fixation sys-tems and substantial technical refinementshave given way to the development ofminimally invasive surgical protocols.14

Together with the routine use of hypoten-sive anaesthesia and subsequent reductionin bleeding and oedema, this fact hasconsolidated orthognathic surgery as asafe, reliable procedure that can often beperformed in an outpatient context.15 Inthe orthodontic field, the introduction ofTADs has given way to a wide range ofnew anchorage possibilities, increasedorthodontic efficiency, and reduced treat-ment times.16–19

The orthognathic surgery patient ‘pro-totype’ has changed too. The desire toimprove facial aesthetics – rather than justcorrecting a dysfunctional occlusion – hasbecome the primary motivation for treat-ment in many cases. This aspiration foraesthetic upgrading, together with thepopular perception of surgery as safeand predictable, is widening the numberand age range of patients who becomeinvolved in orthodontic or combinedorthodontic–surgical therapy. Indeed, thenumber of adult patients, with subsequentperiodontal involvement and job-time lim-itations for long treatments, has increasedsignificantly.1 Some of these patients areorthodontically compensated individualswho are nevertheless unhappy with theaesthetic outcome and have eventuallydecided upon surgical correction of theirdeformity. Others are patients with SDB,often at a phase of OSA, who requireimmediate expansion of the oropharyn-geal airway through counter-clockwiserotation and advancement of the maxillo-mandibular complex and cannot – or willnot – undergo regular preoperative ortho-dontic preparation. As a result, these newpatient profiles have led to a profoundrevision in the traditional timing schemefor orthognathic surgery and novel treat-ment options have arisen.

In an attempt to define and classify thesenew timing approaches, the authors of thispaper carried out a retrospective analysisof all orthognathic procedures performedat a specialized centre for orthognathicsurgery since June 2010. This particulardate was chosen as the starting point of theevaluation because it coincided with theintroduction of a formal treatment proto-col for ‘surgery first’. However, the timingof orthognathic surgery is not simplyplanned with a ‘traditional perspective’or a ‘surgery first perspective’. Our casereview revealed that, at least in our prac-tice, surgery takes place at different points

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Table 2. Variables influencing orthognathic surgery timing.

Variable Common situations

Patient-specific variablesChief complaint and main motivation for surgery Occlusion

Facial aestheticsOSA

Opportunity or willingness to adapt his/her personal agendato the surgical procedure

Flexible agendaJob/time limitations

Opportunity or willingness to adapt his/her personal agendato the required orthodontic appointments

Flexible agendaJob/time limitations

Underlying conditions that may compromise surgery or orthodontics Active periodontal condition contraindicating demandingorthodontic movementsActive TMJ disease or symptoms contraindicating anunstable occlusion and large occlusal plane changes

Occlusal characteristics Severe crowding3D dental compensationsTransverse compromise in need of SARPE

Orthodontist-specific variablesPrevious experience with orthognathic surgery casesmanaged with the traditional timing approach

Broad experienceLimited experience

Previous experience with TAD Broad experienceLimited experience

Surgeon-specific variablesPrevious experience with orthognathic surgery casesmanaged with the traditional timing approach

Broad experienceLimited experience

OSA, obstructive sleep apnoea; TMJ, temporomandibular joint; 3D, three-dimensional; SARPE, surgically assisted rapid palatal expansion; TAD,temporary anchoring devices.

along the orthodontic treatment timeline.These particular time points, which arealways case-specific and decided by con-sensus between the orthodontist, surgeon,and patient, are influenced by several vari-ables (Table 2). According to these, theoptimal timing approach is selected from atotal of six possibilities: (1) ‘surgery first’,(2) ‘surgery early’, (3) ‘surgery late’, (4)‘surgery last’, (5) ‘surgery only’, and (6)‘surgery never’.

In a ‘surgery first’ approach, surgery isperformed directly with no preoperativeorthodontic phase. Our preliminaryexperience with this treatment modalitytogether with a standardized workflowmodel has been reported recently.1,5 Com-pared to conventional timing, a substantialreduction in the total treatment time wasachieved. Indeed, this study revealed thatthe mean treatment time with ‘surgerylate’ (97.5 weeks) was more than doublethe time required for a ‘surgery first’ pro-tocol (45.3 weeks), even though the aver-age number of orthodontic appointmentswas similar (29 for ‘surgery late’, 21 for‘surgery first’). This shortened treatmenttime can be explained by the high ortho-dontic efficiency resulting from the surgi-cally induced RAP1,2,7 plus the onset oforthodontic treatment after skeletal basecorrection.5 Our results show that as manyas 18.8% of our cases were treated with a‘surgery first’ approach. However, it mustbe emphasized that careful patient selec-

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tion is absolutely essential. First and fore-most, the chief complaint should be eitherfacial aesthetics or SDB. In our opinion, apatient whose prime motivation for sur-gery is the attainment of a perfect occlu-sion is not a good candidate for ‘surgeryfirst’, since more predictable orthodonticresults can probably be attained with otherapproaches. Secondly, and in agreementwith other authors,20 our protocolexcludes patients with severe crowdingin need of extractions and cases of classII second division with overbite, i.e., casesin which the inferior curve of Spee isseverely altered. Cases requiring SARPEto achieve an adequate transverse maxil-lary dimension, or severe asymmetrieswith 3D dental compensations, are cur-rently disregarded for ‘surgery first’ too. Inour hands, these scenarios appear toocomplex to anticipate the final occlusionaccurately. Moreover, 3D dental compen-sations can significantly impair immediatepostsurgical stability. Finally, patientswith TMJ symptoms or uncontrolled per-iodontal disease are automaticallyexcluded from the ‘surgery first’ approachon the basis of an unstable postoperativeocclusion and excessively demanding orrisky orthodontic movements, respec-tively.

Despite this systematized inclusion–exclusion criteria list, the orthodontistshould have the last word in patient selec-tion. Indeed, while a ‘surgery first’ proto-

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col does not entail greater proceduralcomplexity from a surgical point of view,it can be very technically demanding forthe orthodontist.1,4,5 In our protocol, apreoperative 3D virtual orthodontic setupis absolutely essential in order to antici-pate the future dental movements. Theorthodontist must be familiarized withthe use of TADs and be prepared for arather stressful patient follow-up; toothmovements should begin no later than 2weeks after surgery in order to benefitfrom the surgically stimulated RAP, andarchwires must be changed every secondto third week. Consequently, we believeorthodontists who become involved with‘surgery first’ timing should have a broadexperience in orthognathic surgery withthe classical (‘surgery late’) approach.

An important advantage of a ‘surgeryfirst’ sequence is the fact that patients candecide for themselves the surgicalappointment date without the need to waitfor complete arch levelling and decom-pensation. The lack of preoperative axialcorrection of the incisors is also an impor-tant advantage for skeletal class IIIpatients, in whom orthodontic preparationtends to exacerbate a compensated ante-rior crossbite, thereby accentuating theprognathic profile and intensifying thepatient’s perception of facial disharmony.1

Conversely, if surgery is performed priorto orthodontics, the total treatment time isnoticeably reduced. The skeletal problem

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– and therefore the aesthetic concern – iscorrected from the beginning.1,6 This cir-cumstance has a very positive influence onpatient compliance with postoperativeorthodontics and is a powerful contributorto global satisfaction with treatment.5

However, it is often the case that patientswith a predominantly aesthetic concernand the wish for prompt surgical correc-tion – thereby requiring a ‘surgery first’approach – present with severe crowdingin need of extractions and/or complex 3Ddental compensations due to skeletalasymmetry. In these cases, a ‘surgeryearly’ approach is followed. This timingmodality is very similar to ‘surgery first’,with the exception that a brief preopera-tive orthodontic phase takes place. In thecase of severe crowding, surgery can pro-ceed as soon as most of the necessaryspace closure after tooth extractions hasbeen completed. If severe 3D compensa-tions and or dental midline deviations arepresent, the requisite for surgery is thatcorrections in the transverse dimension areattained. At any rate, complete levellingand decompensation are not necessary.Another indication for this ‘surgery early’approach is patients who are candidatesfor ‘surgery first’, but due to personallogistical reasons – academic, professional– need to delay surgery. Until such time asan appropriate date for the surgicalappointment is fixed, orthodontic treat-ment anticipates some dental movementsbefore surgery. The surgical procedureand postoperative orthodontic treatmentproceed with the same particularities asfor a ‘surgery first’ approach. Conse-quently, a high degree of orthodonticexpertise is also essential.

Despite these relatively innovative ‘sur-gery first’ and ‘surgery early’ timingschemes, ‘surgery late’ – in other words,the conventional timing approach – con-tinues to be the most frequently indicatedmethodology in our hands (72.1%). It iswell known that traditional surgical–orthodontic treatment comprises twoorthodontic phases: a preoperative pre-paration where most of the orthodonticmovements are performed to achieve adecompensated, levelled occlusion (withor without the anticipation of maxillarysegmentation), and a postoperative phasefor minor adjustments. Preoperative ortho-dontics usually requires 15–17months,21,22 sometimes even up to 24months.23 The postoperative orthodonticphase has been reported to last an averageof 7 months21 to 12 months.23 At any rate,total orthodontic treatment is frequentlylonger than what is initially indicated tothe patient.1,21 In addition, some patients,

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especially skeletal class III, are extremelyreluctant to accept the aesthetic decayassociated with dental decompensation.Finally, another disadvantage of thisscheme is the fact that surgery timing isstrictly conditioned by orthodontic treat-ment. Thus, the patient must agree to anexternally imposed surgical appointmentdate. Despite these drawbacks, however,‘surgery late’ continues to be the mostpredictable timing scheme to attain occlu-sal normalization. As such, it should be theway to go in cases where the final 3Ddental position cannot be accurately fore-seen or guaranteed, when complex 3Ddental movements are anticipated, orwhen the patient’s main motivation forsurgery is the achievement of an optimalocclusion. Finally, surgeons or orthodon-tists with limited experience in orthog-nathic surgery or TADs should alsoselect this approach. In our ‘surgery late’protocol, surgery proceeds in a standardfashion, i.e., the regular facial osteotomiesare performed with no additional inter-dental corticotomies. The use of TADsis reserved for cases of maxillary segmen-tation, where miniscrews are used forvertical control anteriorly and for verticaland transversal control posteriorly.

Our retrospective evaluation revealed asmall group of patients who were treatedwith a special timing methodology, the so-termed ‘surgery last’. The typical patientprototype of this category is an individualwho has declined orthognathic surgery inthe past and has undergone compensatoryorthodontic treatment that has resulted in astable functional occlusion; at some point,however, the patient becomes concernedwith aesthetics and decides to seek surgi-cal skeletal correction. In our practice, thenumber of patients in such a situation issteadily increasing. The mean age of thisgroup of patients – and the level of period-ontal compromise – tends to be higherthan in patients involved in a ‘surgeryfirst’, ‘surgery early’, or ‘surgery late’protocol. When a clinician is confrontedwith a case of this type, two possibilitiesexist: (1) the occlusion is inappropriateand requires some type of orthodontictreatment; in this case, one of the pre-viously described approaches – ‘surgeryfirst’, ‘surgery early’, or ‘surgery late’ –can be followed; (2) the occlusion isindeed a stable, functional, class I occlu-sion. In this latter scenario, one alternativewould be to initiate a standard decompen-sation orthodontic treatment that wouldprobably include reopening of extractionspaces. Besides the substantial amount oftime that this orthodontic retreatmentimplies, alveolar bone compromise and

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the risk of root resorption is often a stronglimiting factor. In addition, many patientsare very reluctant to undergo another longorthodontic treatment to undo what waspreviously accomplished. In the past,when surgeons contemplated skeletalmovements in the sagittal and verticaldimensions only, this was, nevertheless,the standard approach; the orthodontistwould recuperate the pre-orthodonticmaxillomandibular discrepancy such thatsurgery could simultaneously correctocclusion and facial harmony. For yearsnow, most orthognathic surgeons haveacknowledged that rotational movementsof the maxillomandibular complex need tobe incorporated into the surgical plan inorder to achieve adequate projections ofthe different facial components andthereby maximize aesthetic results.24,25

This principle is applied in what we callthe ‘surgery last’ scheme. Therefore, if thepatient has a stable functional occlusion,we opt for no further orthodontic prepara-tion. Instead, an occlusal plane change isintroduced with clockwise or counter-clockwise rotation of the maxillomandib-ular complex. In this way, facial harmonyis restored while the patient’s preoperativeocclusion is maintained. Incorrect dentalinclinations that resulted from previousorthodontic compensation – in particular,the characteristic over-torqued incisors ofcompensated class II and class III patients– can hence be readjusted. From an ortho-dontic point of view, it could be arguedthat such a procedure does not correctdental inclinations with regards to theskeletal bases. However, they are restoredwith regards to the facial complex, whichis what produces facial improvement. Nopostoperative orthodontic treatment fol-lows. This means that surgery is the cri-tical step that governs the final outcome,with the key particularity that the preo-perative occlusion must remain intact. Inour protocol, miniscrews are used forintraoperative intermaxillary fixation andpostoperative elastic mechanics. Finally, itmust be mentioned that ‘surgery last’patients with less ambitious aestheticdemands can be satisfactorily managedwith a camouflaging genioplasty and orancillary cosmetic procedures.

As in a ‘surgery last’ approach, a ‘sur-gery only’ protocol proceeds directly withsurgery without any subsequent orthodon-tic treatment. The difference between thetwo timing schemes is the fact that in a‘surgery only’ situation, the patient has notreceived any previous orthodontic treat-ment in the past either. In other words, thecase is managed entirely with surgery.In our practice, this approach is strictly

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Table 3. Comparison between the six surgical timing options.

‘Surgery first’ ‘Surgery early’ ‘Surgery late’ ‘Surgery last’ ‘Surgery only’ ‘Surgery never’

Aesthetic motivation +++ +++ ++ +++ +++ �Occlusal motivation + ++ +++ � � +++Respiratory motivation (OSA) +++ +++ � +++ +++ �3D virtual orthodontic setup +++ +++ + � � +Patient decides timing +++ ++ + +++ +++ NAPreoperative orthodontics � + ++ +++ � NAUse of TAD (miniscrews) +++ +++ � +++ +++ +Corticotomies to increase the RAP +++ +++ � � � +Orthodontic complexity +++ +++ + NA NA +++Surgical complexity ++ ++ + +++ +++ NA

OSA, obstructive sleep apnoea; 3D, three-dimensional; TAD, temporary anchoring devices; RAP, regional acceleratory phenomenon; NA, notapplicable.

Fig. 17. The selection of timing according to patient-specific variables. Patients whose mainmotivation for treatment is obstructive sleep apnoea can be managed with a ‘surgery only’approach if they present a stable functional occlusion and/or they reject orthodontic treatment. Iforthodontic treatment is acceptable, the airway volume may be increased with a ‘surgery first’approach, followed by orthodontics. When the chief complaint is facial aesthetics, a ‘surgeryfirst’ approach may be considered if the patient’s baseline occlusal characteristics do not hinderan accurate prognostication of the end occlusion and the orthodontist has sufficient experience inorthognathic surgery. If the end occlusion cannot be reliably foreseen, a ‘surgery early approach’is preferred. Inexperienced orthodontists, however, should preferably follow a conventional‘surgery late’ scheme. Patients who reject orthodontic treatment or whose occlusal conditionmakes the benefit of orthodontics questionable or irrelevant (partial or total edentulous) can bemanaged with a ‘surgery only’ approach. If occlusal optimization is the main motivation fortreatment, a ‘surgery late’ modality is the preferred approach. However, if the patient refusessurgery, ‘surgery never’ (i.e., orthodontic compensation) may be considered as long as aestheticdecay does not occur and the patient understands the limitations of this option. Should a patientwho has been orthodontically compensated eventually become concerned with aesthetics, a‘surgery last’ approach may be considered.

limited to three specific scenarios: (1)patients whose chief complaint is facialaesthetics and who present a stable func-tional occlusion as confirmed by studymodels; (2) partial or total edentulouspatients in whom orthodontic treatmentwould add little or no benefit to the finaloutcome, and in whom a combinedprosthodontic–surgical (orthognathic sur-gery plus implant placement) managementis foreseen; and (3) patients with OSA anda stable occlusion in whom the treatment

Please cite this article in press as: Hernande

intervention in orthognathic surgery, Int J O

goal is to increase the airway volume, andwho reject additional orthodontic treat-ment. In all these three situations, it isrequired that the preoperative occlusalrelationship be maintained. Consequently,as in a ‘surgery last’ approach, the treat-ment basis is occlusal plane correctionthrough rotational–translational move-ments of the maxillomandibular complex.

It is important to emphasize the factthat, while a high degree of orthodonticexpertise is essential for the ‘surgery first’

z-Alfaro F, Guijarro-Martınez R. On a definit

ral Maxillofac Surg (2014), http://dx.doi.org

and ‘surgery early’ timing approaches, the‘surgery last’ and ‘surgery only’ modal-ities represent the most demanding surgi-cal scenarios. Considering that nopostoperative orthodontic treatment isanticipated, skeletal repositioning mustbe precise enough to correct the aestheticor respiratory problem while maintainingthe preoperative occlusion. Any slightdeviation from this aim can render thepostoperative occlusion unstable. Thus,only expert surgeons should becomeinvolved with these two modalities.

The last treatment timing option is thatin which surgery does not take place at all.This ‘surgery never’ category is com-prised of patients with documenteddento-maxillofacial deformities whoreject any type of surgical formula, andwhose treatment motivation is exclusivelyocclusion-based. These patients tend to bemanaged with orthodontic compensation,which, in expert hands, can produce astable and functional occlusion. As longas this option does not provoke facialdecay and the patient understands its lim-itations, it can be a reasonable compro-mise option. High orthodontic expertise iscritical in these cases in order to avoidrelapse-prone movements and periodontalcompromise. Some of these patients couldeventually benefit from the previouslydiscussed ‘surgery last’ approach.

Table 3 offers a comparison betweenthe six treatment timing modalitiesregarding patient motivation, treatmentplanning, orthodontic and surgical man-agement, and technical particularities.Figure 17 shows a simple algorithm toaid in the preliminary selection approach.

If the clinician acknowledges thepatient’s complaints, wishes, and expec-tations as the primary guidelines for indi-vidualized treatment planning, timing fororthognathic surgery can no longer beconceived as a constant, inflexible dogmavalid for all patients and all therapeuticcontexts. On the contrary, the contempor-ary management of dento-maxillofacial

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10 Hernandez-Alfaro and Guijarro-Martınez

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deformities must be based on a compre-hensive analysis of various patient-,orthodontist-, and surgeon-specific vari-ables. Moreover, the timing particulari-ties of each treatment approach requirethe contemplation of specific orthodonticand surgical techniques aimed at enhan-cing the final outcome while minimizingpatient morbidity and financial costs.

Funding

None.

Competing interests

None declared.

Ethical approval

Approved by the Committee on EthicalMedical Practice of the Teknon MedicalCentre (Ref. 2013FHA005).

Patient consent

Written patient consent was obtained touse clinical photographs and radiologicaldata.

References

1. Hernandez-Alfaro F, Guijarro-Martınez R,

Molina-Coral A, Badia-Escriche C. ‘‘Surgery

first’’ in bimaxillary orthognathic surgery. J

Oral Maxillofac Surg 2011;69:e201–7.

2. Liou EJ, Chen PH, Wang YC, Yu CC, Huang

CS, Chen YR. Surgery-first accelerated

orthognathic surgery: postoperative rapid

orthodontic tooth movement. J Oral Max-

illofac Surg 2011;69:781–5.

3. Nagasaka H, Sugawara J, Kawamura H,

Nanda R. ‘‘Surgery first’’ skeletal class III

correction using the Skeletal Anchorage Sys-

tem. J Clin Orthod 2009;43:97–105.

4. Sugawara J, Aymach Z, Nagasaka DH,

Kawamura H, Nanda R. ‘‘Surgery first’’

orthognathics to correct a skeletal class II

malocclusion with an impinging bite. J Clin

Orthod 2010;44:429–38.

5. Hernandez Alfaro F, Guijarro-Martınez R,

Peiro-Guijarro MA. Surgery first in orthog-

Please cite this article in press as: Hernande

intervention in orthognathic surgery, Int J O

nathic surgery: what have we learned? A

comprehensive workflow based on 45 con-

secutive cases. J Oral Maxillofac Surg 2014;

72:376–90.

6. Villegas C, Janakiraman N, Uribe F, Nanda

R. Rotation of the maxillomandibular com-

plex to enhance esthetics using a ‘‘surgery

first’’ approach. J Clin Orthod 2012;46:

85–91.

7. Villegas C, Uribe F, Sugawara J, Nanda R.

Expedited correction of significant dentofa-

cial asymmetry using a ‘‘surgery first’’

approach. J Clin Orthod 2010;44:97–103.

8. Wilcko WM, Wilcko T, Bouquot JE, Fergu-

son DJ. Rapid orthodontics with alveolar

reshaping: two case reports of decrowding.

Int J Periodontics Restorative Dent

2001;21:9–19.

9. Sebaoun JD, Ferguson DJ, Wilcko MT,

Wilcko WM. Alveolar osteotomy and rapid

orthodontic treatments. Orthod Fr

2007;78:217–25.

10. Wilcko MT, Wilcko WM, Pulver JJ, Bissada

NF, Bouquot JE. Accelerated osteogenic

orthodontics technique: a 1-stage surgically

facilitated rapid orthodontic technique with

alveolar augmentation. J Oral Maxillofac

Surg 2009;67:2149–59.

11. Strippoli J, Aknin JJ. Accelerated tooth

movement by alveolar corticotomy or piezo-

cision. Orthod Fr 2012;83:155–64.

12. Frost HM. The biology of fracture healing.

An overview for clinicians. Part I. Clin

Orthop Relat Res 1989;(248):283–93.

13. Hernandez-Alfaro F, Guijarro-Martınez R.

Endoscopically assisted tunnel approach

for minimally invasive corticotomies: a pre-

liminary report. J Periodontol 2012;83:

574–80.

14. Hernandez-Alfaro F, Guijarro-Martınez R.

‘‘Twist technique’’ for pterygomaxillary

dysjunction in minimally invasive Le Fort

I osteotomy. J Oral Maxillofac Surg

2013;71:389–92.

15. Cangemi Jr CF. Administration of general

anesthesia for outpatient orthognathic surgi-

cal procedures. J Oral Maxillofac Surg

2011;69:798–807.

16. Yao CC, Lai EH, Chang JZ, Chen I, Chen YJ.

Comparison of treatment outcomes between

skeletal anchorage and extraoral anchorage

in adults with maxillary dentoalveolar pro-

trusion. Am J Orthod Dentofacial Orthop

2008;134:615–24.

z-Alfaro F, Guijarro-Martınez R. On a definit

ral Maxillofac Surg (2014), http://dx.doi.org/

17. Chung KR, Kim SH, Lee BS. Speedy surgi-

cal–orthodontic treatment with temporary

anchorage devices as an alternative to

orthognathic surgery. Am J Orthod Dentofa-

cial Orthop 2009;135:787–98.

18. Mimura H. Treatment of severe bimaxillary

protrusion with miniscrew anchorage: treat-

ment and complications. Aust Orthod J

2008;24:156–63.

19. Upadhyay M, Yadav S, Nanda R. Vertical-

dimension control during en-masse retraction

with mini-implant anchorage. Am J Orthod

Dentofacial Orthop 2010;138:96–108.

20. Liou EJ, Chen PH, Wang YC, Yu CC, Huang

CS, Chen YR. Surgery-first accelerated

orthognathic surgery: orthodontic guidelines

and setup for model surgery. J Oral Max-

illofac Surg 2011;69:771–80.

21. Luther F, Morris DO, Hart C. Orthodontic

preparation for orthognathic surgery: how

long does it take and why? A retrospective

study. Br J Oral Maxillofac Surg 2003;41:

401–6.

22. Dowling PA, Espeland L, Krogstad O, Sten-

vik A, Kelly A. Duration of orthodontic

treatment involving orthognathic surgery.

Int J Adult Orthodon Orthognath Surg

1999;14:146–52.

23. Diaz PM, Garcia RG, Gias LN, Aguirre-

Jaime A, Perez JS, de la Plata MM, Navarro

EV, Gonzalez FJ. Time used for orthodontic

surgical treatment of dentofacial deformities

in white patients. J Oral Maxillofac Surg

2010;68:88–92.

24. Wolford LM, Chemello PD, Hilliard F.

Occlusal plane alteration in orthognathic

surgery—part I: effects on function and

esthetics. Am J Orthod Dentofacial Orthop

1994;106:304–16.

25. Chemello PD, Wolford LM, Buschang PH.

Occlusal plane alteration in orthognathic

surgery—part II: long-term stability of

results. Am J Orthod Dentofacial Orthop

1994;106:434–40.

Address:Raquel Guijarro-MartınezInstitute of Maxillofacial SurgeryTeknon Medical Centre BarcelonaVilana 12D-18508022 BarcelonaSpainE-mail: guijarro.raq@gmail.com

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