surgery first approach is explained

1. Dr Maher Fouda
Professor of orthodontics
Faculty of Dentistry
Mansoura Egypt
SURGERY FIRST

2. In recent years, a trend toward implementing treatment
plans that achieve rapid facial change has arisen. In
the surgery first (SF) treatment plan, the presurgical
orthodontic treatment phase is completely eliminated, the
jaws are surgically repositioned to the desired locations,
and orthodontic tooth movement follows. Caution is important
when embarking on SF treatment.
Immediate postsurgical
intraoral images showing a
transitional
occlusion
Posttreatment intraoral images
showing achievement of
normal overjet and overbite
Intraoral images showing
bonded teeth with 0.022 ‫״‬
preadjusted brackets and
ligated with 0.010 ‫״‬ligature
wire
Pretreatment
intraoral
photographs
Surgery-first orthognathic approach case series: Salient
features and guidelines
2016 Journal of Orthodontic Science

3. Even a highly experienced
orthodontist/surgeon will not necessarily find it
easy to identify the occlusal relationship that will accompany
an ideal facial and functional result. This explains why
numerous orthodontists prefer to conduct an orthodontic
preparation before surgery. Having a stable postoperative
occlusion is thought to be important for maintaining the
bony stability.
A. Intermediate splint in
position during maxillary
advancement surgery.
Final .019" × .025" TMA*
archwire in place.
Treatment in 41 Days Using a Customized
Passive Self-Ligation System and the
“Surgery First” Approach
21-year-old male patient with
mild Class III malocclusion,

4. The advent of temporary anchorage devices (TADs),
including skeletal anchorage, was a breakthrough in achieving
teeth movement beyond traditional orthodontics. The
skeletal anchorage system (SAS), which uses titanium miniplates
to control moving teeth in nongrowing patients, has
shown that it is possible to achieve predictable three dimensional
movement of teeth and entire dentition with
fewer bicuspid extractions.
Thirty days before surgery,
customized lingual
appliances
were
placed
During the surgery,
4 miniplates were also installed, one on each side of
the
zygomatic pillar, between the maxillary first and
second molar, and one on each side of the
mandible, between
the canine and the mandibular first premolar. The
final splint was removed after surgery.
Retreatment of a patient: Orthognathic
surgery-first approach with customized
lingual appliances combined with
miniplate anchorage
American Journal of Orthodontics
and Dentofacial Orthopedics
November 2019 Vol 156 Issue 5

5. Contemplating SF treatment with the SAS began in 2003
at Tohoku University in Sendai, Japan. The distinguishing
feature of this approach is an orthodontics-driven method
referred to as Sendai SF. The surgery aims to first correct the
skeletal deformity and then the SAS mini-plates, which are
placed at the time of orthognathic surgery, manage the dentoalveolar
problems and establish the functional and esthetic
occlusion postsurgically.
Model surgery and surgical
splint showing bilateral 7mm
mandibular setback.
Patient immediately after
surgery, postsurgical orthodontic treatment,
using the
SAS
JCO/FEBRUARY 2009
“Surgery First” Skeletal Class
III Correction
Using the Skeletal Anchorage
System

6. The fundamental concept of Sendai
SF is to maintain the quality results seen in traditional surgical
orthodontics by making a precise prediction of the final
outcomes of both orthodontic and surgical correction prior
to treatment.
.

11. SENDAI SURGERY FIRST PROTOCOL
The Sendai SF protocol has 15 steps . Among these
are four major steps, each of which is discussed below and
illustrated with a detailed patient case example.

12. Step 1: Diagnosis (Establishment
of Treatment Goals)
Individualized treatment goals in Sendai SF are
established
at the initial time of treatment. This process is led by
examining
and analyzing the problem list developed for each
patient. In our case example, a 37-year-old female
presented
with a prognathic profile and long face with facial
asymmetry,
an anterior open bite, and significant retroclination of
the lower incisors.

13. Initial (A–C) facial and (D–I) intraoral photos of a 37-year-old female patient
show a prognathic profile, long face, Class I dental relationship,
anterior crossbite, open bite, and retroclination of the lower incisors.

14. According to the posteroanterior
(PA) cephalometric radiograph, she had clear
mandibular
asymmetry. Cephalometric analysis to evaluate
skeletal
discrepancies was conducted based on five
parameters:
cephalometric template analysis (CDS analysis),
McNamara
analysis for points A and B, the A point nasion B
point
(ANB) angle, Wits appraisal, and Harvold analysis .

15. 1. CDS analysis
2. McNamara analysis (A: 1.0 B: 1.2)
3. ANB (0.5)
4. Wits appraisal (14.5)
5. Harvold analysis (45.0)
Cephalometric analysis. The line drawing indicates patient (white) and
norm (blue). Clearly, the patient’s mandibular protrusion and excessive
lower facial height could best be corrected surgically. A, A point; ANB, A
point nasion B point; B, B point; CDS, cephalometric template analysis.

16. Results of the cephalometric analysis revealed her
mandibular excess and excessive lower facial height due to
vertical maxillary excess. These findings indicated her need
for surgical correction with mandibular setback and reduction
of lower facial height.

17. Based on the results of the cephalometric analysis, the
patient’s treatment goals were established. The
amount of mandibular setback and the extent of decompensation
of the incisors were evaluated as well. The amount of
mandibular setback was predicted to be 10-mm on average
and her denture relationship changed from Class III to Class
II with open bite. In postsurgical orthodontics, 3-mm intrusion
of upper molars and 5-mm protraction of lower dentition
were needed to achieve the successful decompensation
of her lower incisors and good Class I occlusion.

18. Treatment goals. Cephalometric
prediction (A) immediately after
surgery and (B) at debonding.
The amount of mandibular
setback and the
extent of decompensation of the
incisors were predicted. In
postsurgical orthodontics, 3-
mm intrusion of upper molars
and 5-mm protraction of lower
dentition
were needed to achieve the
successful decompensation of
the patient’s lower incisors and
good Class I occlusion. By
using the skeletal anchorage
system
(SAS) to intrude the maxillary
posteriors, the need for two-jaw
surgery was eliminated.

19. If using conventional surgical orthodontics, the patient
would have been a candidate for two-jaw surgery since she
had vertical problems in conjunction with anteroposterior
and transverse problems. By using the SAS to intrude the
maxillary posterior teeth, the need for two-jaw surgery was
eliminated; the less invasive one-jaw surgical approach was
all that was required.

20. At least 1 week before surgery, brackets were bonded indirectly
and passive rectangular wires for stabilizing dentition
and bone segments were prepared by a dental technician in
a laboratory. The brackets and archwires were 0.022-inch and
0.016-inch × 0.022-inch stainless steel, respectively. Surgical
hooks were soldered on the archwire .
Indirect bonding and surgical wires. The
passive rectangular surgical wires
(0.016-inch × 0.022-inch stainless steel)
for stabilizing dentition and
bone segments were prepared by a
dental technician in a laboratory. A, The
passive wire bent on a model after the
brackets indirectly bonded; frontal view.
B, The passive wire with the surgical
hooks soldered; intraoral frontal view. C,
Lateral model view. D, Lateral intraoral
view.

21. Step 2: Model Surgery
Model surgery is an essential step in Sendai SF and leads to
the fabrication of the surgical splint that will maintain the
transit occlusion postsurgically.
A–C, Model prediction with
semiadjustable articulator. Based on the
cephalometric prediction, the patient’s
mandibular model was setback
13-mm on the right side and 7-mm on the
left side. D, Mandibular setback should be
parallel to the functional occlusal plane to
not increase the posterior
facial height. Many Class III cases show
Class II open bite at that point in the
treatment, because of the occlusal
interferences at the molar regions. E–G, A
surgical splint with four ball hooks is
essential to maximize the occlusal
contact and to stabilize posterior support
immediately after surgery. The splint is
usually placed at the mandibular

22. The facebow transfer process is used to transfer the maxillary
model followed by the mandibular model onto a semiadjustable
articulator. Based on the cephalometric prediction,
the surgical movement is simulated. The patient needed
mandibular setback of 13-mm on the right and 7-mm on the left .
.
A–C, Model prediction with semiadjustable
articulator. Based on the cephalometric
prediction, the patient’s mandibular model
was setback
13-mm on the right side and 7-mm on the
left side. D, Mandibular setback should be
parallel to the functional occlusal plane to
not increase the posterior
facial height. Many Class III cases show
Class II open bite at that point in the
treatment, because of the occlusal
interferences at the molar regions. E–G, A
surgical splint with four ball hooks is
essential to maximize the occlusal contact
and to stabilize posterior support
immediately after surgery. The splint is
usually placed at the mandibular dentition in
Class III cases.

23. The surgical simulation of mandibular
movement should be parallel to the functional occlusal plane
so that the posterior facial height is maintained,
As a result, many Class III cases will show Class II open
bite immediately after surgery due to the occlusal interferences
at the molar regions
A–C, Model prediction with semiadjustable
articulator. Based on the cephalometric
prediction, the patient’s mandibular model
was setback
13-mm on the right side and 7-mm on the left
side. D, Mandibular setback should be
parallel to the functional occlusal plane to
not increase the posterior
facial height. Many Class III cases show
Class II open bite at that point in the
treatment, because of the occlusal
interferences at the molar regions. E–G, A
surgical splint with four ball hooks is
essential to maximize the occlusal contact
and to stabilize posterior support
immediately after surgery. The splint is
usually placed at the mandibular dentition in
Class III cases.

24. Other groups that promote SF treatment recommend
establishing three-point contacts in model surgery to acquire
stable occlusion and Class I molar relationships immediately
after orthognathic surgery This is not necessarily
required in Sendai SF. The surgical movement is aimed to
correct the skeletal disharmony. It is the role of the SAS to
achieve the proper occlusion postsurgically. Aymach and
Kawamura described the attempt to achieve a three-point
contact occlusion and close the open bite by counterclockwise
rotation of the mandible will extend the pterygomasseteric
sling due to the increase of posterior facial height.
Such extension of the sling is closely associated with the
postsurgical relapse seen with open bite.

25. Therefore other
SF groups must apply more invasive two-jaw surgery in
order to avoid the increase in posterior facial height.
With the surgical movement simulated, a surgical splint
with four ball hooks and a lingual bar is fabricated . Using a splint
is essential to maximize the occlusal
contact and to stabilize posterior support. Even though
the molars cause occlusal interferences at this point in
the treatment process, no cusp grinding of the molars is
performed.
.
E–G, A
surgical splint with four ball hooks is essential to maximize the occlusal contact and to
stabilize posterior support immediately after surgery. The splint is
usually placed at the mandibular dentition in Class III cases.

26. Since distalization of the maxillary molars and constriction
of the maxillary dentition are needed at the early stage
of postsurgical orthodontics, the surgical splint is usually
placed at the mandibular dentition in Class III cases
E–G, A
surgical splint with four ball hooks is essential to maximize the occlusal contact and
to stabilize posterior support immediately after surgery. The splint is
usually placed at the mandibular dentition in Class III cases.

27. Step 3: Orthognathic Surgery
Accurate surgical technique has a major role in the success
of Sendai SF. Achieving an appropriate osteotomy design,
splitting, fixation technique, and proper condyle seating are
key in conferring stable results.
A, A modified sagittal split ramus osteotomy with buccal step and T-shaped mini-plate fixation; view of the surgical site. Aymach and
Kawamura found this technique optimizes the resistance and stability of the fixation when compared with a standard bilateral sagittal
split osteotomy (BSSO)
fixed with a standard mini-plate. (Note that the orthodontic mini-plates for the skeletal anchorage system [SAS] are placed at the time of
surgery). B, Schematic
view of the T mini-plate fitting and fixating at the site of the buccal step of the osteotomy. C, The SAS placed at the maxillary buttress
area during surgery.
(Note that the hook of the mini-plate extends through the attached gingiva to be used later for orthodontic movement.)

28. The surgeons on the Sendai SF team use a modified design
of a bilateral sagittal split osteotomy (BSSO) combined with
a T-shaped bone mini-plate fixation. The design has a
buccal step laid adjacent to the mandibular second molar
area. This design prevents condylar dislocation and therefore
minimizes relapse .
A, A modified sagittal split ramus osteotomy with buccal step and T-shaped mini-plate fixation; view of the surgical site. Aymach and
Kawamura found this technique optimizes the resistance and stability of the fixation when compared with a standard bilateral sagittal split osteotomy (BSSO)
fixed with a standard mini-plate. (Note that the orthodontic mini-plates for the skeletal anchorage system [SAS] are placed at the time of surgery). B, Schematic
view of the T mini-plate fitting and fixating at the site of the buccal step of the osteotomy. C, The SAS placed at the maxillary buttress area during surgery.
(Note that the hook of the mini-plate extends through the attached gingiva to be used later for orthodontic movement.)

29. Aymach and Kawamura have
shown that for mandibular setback or advancement surgery,
a modified BSSO and buccal step, combined with a T-shaped
bone mini-plate fixation, optimizes the resistance and stability
of the fixation when compared to a standard BSSO fixed
with a single straight bone mini-plate.
A, A modified sagittal split ramus osteotomy with buccal step and T-shaped mini-plate fixation; view of the surgical site. Aymach and
Kawamura found this technique optimizes the resistance and stability of the fixation when compared with a standard bilateral sagittal split osteotomy (BSSO)
fixed with a standard mini-plate. (Note that the orthodontic mini-plates for the skeletal anchorage system [SAS] are placed at the time of surgery). B,
Schematic
view of the T mini-plate fitting and fixating at the site of the buccal step of the osteotomy. C, The SAS placed at the maxillary buttress area during surgery.
(Note that the hook of the mini-plate extends through the attached gingiva to be used later for orthodontic movement.)

30. The authors suggest avoiding the use of positional screws
for osteotomy fixation, as they confer a high potential for
torquing the condyle and consequentially shifting the occlusion.
Using bone mini-plates provides a sufficient semirigid
fixation that allows functional stability under minimal bone
movement.
A, A modified sagittal split ramus osteotomy with buccal step and T-shaped mini-plate fixation; view of the surgical site. Aymach and
Kawamura found this technique optimizes the resistance and stability of the fixation when compared with a standard bilateral sagittal
split osteotomy (BSSO)
fixed with a standard mini-plate. (Note that the orthodontic mini-plates for the skeletal anchorage system [SAS] are placed at the time of
surgery). B, Schematic
view of the T mini-plate fitting and fixating at the site of the buccal step of the osteotomy. C, The SAS placed at the maxillary buttress
area during surgery.
(Note that the hook of the mini-plate extends through the attached gingiva to be used later for orthodontic movement.)

31. The patient underwent modified BSSO for mandibular
setback. Her maxillary right second molar was extracted
because of root fracture. This problem was caused by her
general dentist prior to treatment. During the operation,
Y-type and L-type orthodontic mini-plates were implanted
at the zygomatic buttress and the mandibular body, respectively.
Panoramic radiograph
obtained immediately after
surgery. Orthodontic mini-
plates were implanted at
the zygomatic buttress and
the mandibular
body during surgery

32. Immediately after surgery, the patient
showed Class II profile and Class II denture with open
bite. Although her profile appeared Class II, her skeletal
relationship changed to skeletal Class I. Her mandible was
maintained in the proper position using a surgical splint
and training elastics at the canine regions . No
extraoral appliance, such as a chin cap, was required for maintenance.
A and B, Facial photos and (C)
cephalometric radiograph
obtained 9 days after jaw
surgery. Patient showed a Class
II profile and Class II denture
with open bite. D–F, Her
mandible was maintained in the
proper position using a surgical
split and up-and-down elastics at
the canine regions. Facial
swelling
takes a little bit longer to
resolve.

33. Cephalometric superimposition of images at initial presentation
and 9 days after surgery showed a 10-mm setback
on average, in line with the treatment goal .
Cephalometric superimposition of initial radiograph and radiograph obtained 9 days after surgery.
The patient’s mandible showed a 10-mm
setback on average, in line with the treatment goal.

34. Step 4: Orthodontic Treatment
Orthodontic treatment commonly starts 17 days after surgery.
Usually 3 to 4 weeks are allowed for recovery and to
enhance nutrition. However, in most Sendai SF cases postsurgical
treatment begins 2 to 3 weeks after orthognathic
surgery.
Seventeen days after surgery, when orthodontic treatment
started. Leveling of upper and lower dentition began using 0.016-inch
nickel-titanium (Ni-Ti) archwires. The surgical splint was placed at the
mandibular posteriors and modified to an occlusal splint by flattening the
occlusal surface

35. In the patient, leveling of upper and lower dentition
started using 0.016-inch nickel-titanium (Ni-Ti) archwire. The
surgical splint was placed at the mandibular
posteriors and modified to an occlusal splint by flattening
the occlusal surface. It was used in order to not disturb the
tooth movement of the upper dentition and to help with
eating.
Seventeen days after surgery, when orthodontic treatment
started. Leveling of upper and lower dentition began using 0.016-inch
nickel-titanium (Ni-Ti) archwires. The surgical splint was placed at the
mandibular posteriors and modified to an occlusal splint by flattening the
occlusal surface.

36. Two months after surgery, rectangular Ni-Ti archwires
were engaged and intrusion and distalization of maxillary
molars and protraction of mandibular dentition were
carried out . The occlusal splint was discontinued
at that time..
Two months after surgery (lateral view). A, Rectangular nickel-titanium (Ni-Ti) archwires were engaged and intrusion and distalization of
maxillary molars and protraction of mandibular dentition were carried out. The occlusal splint was discontinued at that time. B, Skeletal anchorage system
(SAS) biomechanics are also applied at this stage. The photo shows SAS biomechanics that were applied to the patient. In combination with intrusion and
distalization of maxillary dentition and protraction of mandibular dentition, the patient’s Class II denture will be improved quickly.

37. In combination with intrusion and distalization
of the maxillary posterior teeth and protraction of the mandibular
dentition using SAS biomechanics, correction of her
Class II denture was started. In addition to correction of the
anteroposterior and vertical problems, transverse correction
was needed. Constriction of the maxillary arch with buccolingual
archwires was performed to allow for transverse decompensation .
Two months after surgery (lateral view). A, Rectangular nickel-titanium (Ni-Ti) archwires were engaged and intrusion and distalization of
maxillary molars and protraction of mandibular dentition were carried out. The occlusal splint was discontinued at that time. B, Skeletal anchorage system
(SAS) biomechanics are also applied at this stage. The photo shows SAS biomechanics that were applied to the patient. In combination with intrusion and
distalization of maxillary dentition and protraction of mandibular dentition, the patient’s Class II denture will be improved quickly.

38. Copper-nickel-titanium (Cu-Ni-Ti) archwires (0.019-
inch × 0.025-inch) for mandibular use were engaged buccally
and a 0.032-inch × 0.032-inch TMA lingual arch was
placed . In the lower arch, a 0.019-inch × 0.025-
inch Cu-Ni-Ti archwire for maxillary use was engaged
for expansion of the mandibular arch, as the mandibular
posteriors showed excessive Wilson curve.
Two months after surgery: (A) maxillary
occlusal view and (B) mandibular occlusal
view. The transverse correction on the
maxillary dentition
is shown. Constriction of the maxillary arch
with buccolingual archwires was performed to
allow for transverse decompensation. Copper-
nickel-titanium
(Cu-Ni-Ti) wires (0.019-inch × 0.025-inch) 40°C
for mandibular use were engaged buccally
and a 0.032-inch × 0.032-inch TMA lingual
archwire was placed.
A Cu-Ni-Ti wire (0.019-inch × 0.025-inch) for
maxillary use was engaged for expansion of
the mandibular arch since the mandibular
posteriors showed
excessive Wilson curve

39. In most Class III
cases, occlusal interferences between the functional cusps of
the upper and lower molars occur immediately after mandibular
setback osteotomy because of transverse dental
compensation. To remedy this problem, transverse decompensation
by constriction of the upper arch and expansion
of the lower arch is required.
A, The mechanism of transverse decompensation in Sendai
SF (immediately after surgery). In most Class III cases,
occlusal interferences
between functional cusps of the upper and lower molars
occur immediately after mandibular setback osteotomy
because of transverse dental compensation.
To remedy this problem, transverse decompensation by
constriction of the upper arch and expansion of the lower
arch is required.

40. With SAS biomechanics,
the cusp to fossa relationship at the posterior
teeth is corrected significantly and counterclockwise rotation
of the mandible is then induced . Anterior
open bite is improved and rigid intercuspation is established .
B, After constriction of
the upper arch and expansion of the
lower arch. The correction of the cusp to
fossa relationship at the posterior teeth
is responsible on the counterclockwise
rotation seen during the orthodontic
phase. C, After counterclockwise
rotation of the mandible. The anterior
open bite is improved and rigid
intercuspation
is established. Transverse
decompensation is key to achieving
good occlusion quickly and
successfully in Sendai SF.

41. It is important to note that transverse decompensation is
a key element in achieving good occlusion quickly and successfully
in Sendai SF. To facilitate transverse decompensation
the authors frequently apply a variety of different
mechanics, including cross elastics in combination with a
maxillary constriction lingual arch, an auxiliary expansion
arch in the lower dentition, and SAS for unilateral and/or
bilateral expansion of the lower arch .
Various mechanics for
transverse decompensation.
A, Intermaxillary cross
elastics. B, Constriction
lingual arch for maxillary
constriction.
C, Auxiliary expansion arch
for mandibular expansion. D–
F, Skeletal anchorage system
(SAS) for unilateral
mandibular expansion.

42. Four months after surgery, the patient’s upper and lower
archwires were changed to 0.016-inch × 0.022-inch stainless
steel archwires and coordinated . Distalization
and intrusion of the upper posteriors were carried out for
correction of Class II molar relationship and decompensation
of lower incisors, using Y-type mini-plates.
Four months after surgery. A, Upper and lower 0.016-inch × 0.022-inch stainless
steel wires were used. Distalization and intrusion of the upper
posteriors were carried out for correction of Class II molar relationship and
decompensation of lower incisors using Y-type mini-plates. In addition, since
teeth #12 and #22 were small and needed to be crowned, nickel-titanium (Ni-Ti)
open coil springs were used to make enough space. B, Skeletal anchorage
system (SAS) biomechanics for the distalization and intrusion of the upper

43. Four months after surgery. A, Upper and lower 0.016-inch × 0.022-inch stainless steel wires were used. Distalization
and intrusion of the upper
posteriors were carried out for correction of Class II molar relationship and decompensation of lower incisors using
Y-type mini-plates. In addition, since
teeth #12 and #22 were small and needed to be crowned, nickel-titanium (Ni-Ti) open coil springs were used to make
enough space. B, Skeletal anchorage
system (SAS) biomechanics for the distalization and intrusion of the upper posterior teeth and the protraction of the
entire lower dentition.
and tooth #22 were small and needed to be crowned, Ni-Ti
open coil springs were used to make enough space.
At the same
time, the protraction of the lower dentition was still in progress
using L-type mini-plates. In addition, since tooth #12

44. Distalization of the upper posteriors and protraction of
the lower dentition were completed and a Class I canine and
molar relationship was established 5.4 months after surgery.
The bimaxillary arches were stabilized using
ligature wires and mini-plates .
At 5.4 months after surgery. A, The distalization of the upper posteriors and the protraction of
the lower dentition were completed and Class
I canine and molar relationship was established. B, Skeletal anchorage system (SAS)
biomechanics for stabilization of bimaxillary arches using ligature wires
and mini-plates.

45. The cephalometric superimposition of scans obtained
immediately after surgery and 6.7 months later showed that
the patient’s open bite was corrected by counterclockwise
rotation of the mandible, following intrusion of the upper
molars and transverse decompensation .
Cephalometric superimposition of scans obtained immediately after surgery (top) and 6.7 months later
(bottom). The patient’s open bite was
corrected by counterclockwise rotation of the mandible following intrusion of the upper molars and
transverse decompensation.

46. At 6.7 months after surgery. After making
space, temporary
crowns were put on teeth #12 and #22. Bull
loops were bent in the upper
archwire to close minor spaces at the incisors.
At 7.6 months after surgery,
detailing and finishing were
started.
At 9.2 months after surgery. Occlusal
equilibrium was
carried out before debonding.
Temporary crowns were put on tooth #12 and tooth #22
at 6.7 months after surgery (and after making space). Bull
loops were bent in the upper archwire to close minor spaces
at the incisors . Detailing and finishing commenced
with maxillary and mandibular 0.017-inch × 0.025-
inch stainless steel archwires at 7.6 months after surgery . Occlusal equilibrium was carried
out 9.2 months
after surgery and debonding occurred at 10.7
months after surgery.

47. A, Frontal views of the treatment progress. The severe anterior open bite and the deviation of
lower dental midline were corrected within a
short period of time.
TREATMENT RESULTS AND EVALUATION
Intraoral views of the treatment progress showed that the
patient’s severe anterior open bite and deviation of lower
dental midline were corrected within 9.7 months of
orthodontic
work, after surgery .

48. B, Occlusal views of upper dentition. Notice that inter–first molar width did not change
because constriction mechanics on the upper
arch might have been canceled out by the buccal flaring of molar intrusion.
Occlusal views
of her upper dentition showed that her upper inter-molar
width had not changed because of the constriction of the
upper arch, which may have been canceled out by the buccal
flaring of the molars following intrusion

49. C, Occlusal views of mandibular dentition. Notice that inter–second molar distance increased significantly. It is clear that transverse
decompensation was mainly carried out in the mandibular dentition.
Occlusal views of the mandibular dentition showed that the
inter-molar distance at the second molars increased significantly
It is clear that, in this case, transverse
decompensation was mainly carried out in the mandibular
dentition. Favorable occlusal relationships and proper
anterior teeth overlapping were observed at the end of
treatment.

50. Cephalometric superimposition comparing scans obtained 6 months after surgery and at debonding. There
was no skeletal change and only
minor dental changes were observed.
According to the cephalometric superimposition of scans
obtained 6 months after surgery and at debonding, there
was no skeletal change and only minor dental changes
were observed. That means that major dentofacial changes
occurred in the first 6 months after surgery in Sendai SF

51. A–C, Facial and (D–I) intraoral photos at debonding. Most of the patient’s
orthodontic problems were resolved and she showed a balanced
profile, improved smile, and good functional occlusion.
the patient’s facial and intraoral
photos at debonding. Most of her orthodontic problems
were solved and she presented a balanced profile, improved
smile, and esthetic and functional occlusion

52. 1. CDS analysis
2. McNamara
analysis (A: 1.0
B: 4.5)
3. ANB (3.0)
4. Wits
appraisal (7.5)
5. Harvold
analysis (38.0)
Cephalometric analysis at debonding. The patient’s
mandibular asymmetry was significantly improved.
Judging from the cephalometric template
analysis, her skeletal profile was corrected to Class I,
balanced long face. A, A point; ANB, A point nasion B
point; B, B point; CDS, cephalometric template
analysis.
Judging from
her cephalometric analysis, her skeletal profile was corrected
to skeletal Class I, balanced long face .

53. Cephalometric
superimposition of tracings
before and after treatment.
Clearly the patient’s
skeletal Class III profile and
long face was corrected
by modified BSSO. Her
dental problems were
successfully corrected by
intrusion and distalization
of the upper molars and
protraction of the entire
lower
dentition.
The cephalometric superimposition of scans obtained
before and after treatment clearly show that her skeletal Class
III profile and long face were corrected by modified BSSO.
Her dental problems were successfully corrected by intrusion
and distalization of the maxillary molars and mesialization
of the entire mandibular dentition .

54. Cephalometric
comparison of
treatment goal (A)
and the end result
(B). Notice that the
treatment goal was
predictably
achieved with the
application of
Sendai SF.
cephalometric comparison of treatment goal and end result
indicates that the treatment goal was predictably achieved
with the application of Sendai SF .

55. After postsurgical orthodontic treatment that lasted 9.7
months, all brackets were debonded and the titanium miniplates
and screws were removed under local anesthesia. A
vacuum-formed retainer was placed in the maxillary arch
and a lingual retainer was bonded to the mandibular anterior
teeth.
A–C, Facial and (D–I) intraoral views at 1-year follow-up

56. The total treatment time from bonding to debonding
was 11.7 months. By using SAS to intrude the maxillary
posteriors, the need for two-jaw surgery was eliminated and
only the less invasive one-jaw surgical approach was required.
The patient’s 1-year follow-up visit revealed stable outcomes,
both dentally and facially .
A–C, Facial and (D–I) intraoral views at 1-year follow-up

57. ADVANTAGES OF SENDAI SF
Combining the SF approach and SAS has a number of advantages.
Undoubtedly, one of the most important advantages is
shortened treatment time. Dowling et al. reported that conventional
surgical-orthodontic treatment usually requires 16
months for preoperative orthodontics and 6 months for
postoperative orthodontics.

58. A recent multicenter study
by O’Brien et al. on the effectiveness of orthodontic/
orthognathic surgery care in the United Kingdom mentioned
that treatment duration was longer than commonly
expected, with a mean length of 32.8 months.

59. The authors’ research group compared Sendai SF to conventional
orthodontics first (COF). Two groups worked in
parallel, under almost the same conditions, with a similar
number of patients, a similar female/male ratio, similar age
of patients at the time of surgery, similar surgical methods,
treatment at the same hospital by the same surgeons, and
the same period of orthognathic surgery .

60. A, Comparison of the total treatment time between the Sendai SF group
and the conventional orthodontics first (COF) group. Total treatment
time was defined as the duration from bonding to debonding. The two
groups worked in parallel under almost the same conditions.

61. The
difference was mainly the procedures performed on the
patients. One group used the SF approach with SAS and
the other used COF without any TADs. The Sendai SF group
got results in 12.7 months on average .

62. B, Results show that the
average treatment time in the Sendai SF group was 12.7 months, with many cases
distributed around 9 to 15 months. In contrast, treatment time in the COF
group was 33.7 months on average. There was a significant difference in treatment time
between the two groups. OGS, Orthognathic surgery; SF, surgery first;
TAD, temporary anchorage device.

63. Many
Sendai SF cases intensively distributed between 9 to 15
months. In contrast, the COF group got results in 33.7
months on average. In the patient described, the treatment
length of 12.7 months with Sendai SF appears to be significantly
shorter than treatment time with COF.

64. Interestingly, Luther et al. insisted that there was no
relationship between the durations of preoperative and postoperative
orthodontic treatments. Bone turnover after
orthognathic surgery can significantly accelerate orthodontic
tooth movement.
.

65. Teeth respond to the rapid bone
turnover rate from the regional acceleratory phenomenon
(RAP) in the first 3 to 4 months, resulting in rapid teeth
movement, similar to that seen in the accelerated
osteogenic orthodontics .

66. Difficult orthodontic movements, such as
intrusion and distalization, should be efficiently progressed
during the postsurgical phase

67. Another advantage of Sendai SF is the restored relationship
between the jaws and facial soft tissue, as the lips and
tongue are considered to be an effective force to move teeth.
Consequently, efficient and expedited postsurgical orthodontic
work is achieved. In the described patient,

68. following setback of the mandible her tongue was more in
touch with the lower incisors, which was expected to help
with their decompensation.

69. In addition, the number of bicuspid nonextraction cases
is significantly increased with Sendai SF because SAS enables
distalization of the posterior teeth, taking advantage of the
third molar spaces created following their extraction prior
to orthognathic surgery .
Comparison of maxillary bicuspid
extraction between Sendai SF and
conventional orthodontics first
(COF) groups. Only one Sendai SF
patient
had any upper bicuspids extracted
in this survey while almost half of
the COF patients had to have their
bicuspids extracted. SF, Surgery
first; U4, upper first
bicuspid; U5, upper second
bicuspid.

70. Sendai SF is a less invasive surgery. In many cases, a
one-jaw surgical approach is all that is required to correct
facial deformities. SAS can play a major role in achieving
advanced tooth movement and decompensation, beyond
what is possible with conventional orthodontics. In fact, SAS
has been shown to be a successful treatment option for
patients who need but refuse surgery..

71. Other SF teams
rely on performing an extensive surgery to use the maximum
potential of the regional acceleratory phenomenon, enhance
facial aesthetics, and reduce the complexity of the malocclusion.
Two-jaw surgeries are always preferred

72. As well,
severe transverse discrepancies sometimes lead to two-piece
or three-piece Le Fort I osteotomies. The increase in the
number and complexity of osteotomy procedures poses a
greater risk to the patient, higher cost, and higher risk of
surgical error or relapse.

73. DISADVANTAGES OF SENDAI SF
There are some complications and difficulties associated with
Sendai SF. The treating orthodontist and orthognathic
surgeon must be experienced enough to know the limitations
and possible complications of the treatment.

74. DISADVANTAGES OF SENDAI SF
Occlusion cannot be used as a guide to establish treatment
goals. Predicting the final occlusion is the hardest part
of the Sendai SF approach.

75. DISADVANTAGES OF SENDAI SF
lower models cannot be placed in an ideal occlusion due to
multiple occlusal interferences. If the predicted final occlusion
is not achievable or is not planned accurately, the result
will be far from ideal
In many cases the upper and

76. A surgical splint is essential to guide the repositioning of
the mandible. For the first month after surgery, the modified
removable splint (which must be worn while eating) helps to
stabilize the jaw position and bring the teeth into proper
occlusion, with the aid of seating elastics. When passive
stainless steel wires are placed prior to surgery, each wire
must be bent to rest passively on the surface of each tooth.
.

77. This is a challenging and time-consuming procedure for the
orthodontist, especially when teeth are severely rotated and
misaligned. The indirect bonding technique can be used to
allow for accurate bracket positioning and the passive archwires
can be bent beforehand by a technician

78. The application of SAS for postsurgical orthodontic treatment
is the distinguishing feature of the Sendai SF approach.
The orthodontist must be experienced and skilled in SAS
technique, which is essential to achieving predictable, three
dimensional
molar movement and ensuring that individualized
treatment goals are predictably achieved.

79. ADDITIONAL SENDAI SF CASE EXAMPLES
CASE REPORT 1
The patient presented with a Class III, long face profile
with facial asymmetry. This case was addressed with
orthognathic surgery (modified BSSO and genioplasty)
and SAS for postsurgical orthodontics.

80. ADDITIONAL SENDAI SF CASE EXAMPLES
CASE REPORT 1
The patient presented with a Class III, long face profile
with facial asymmetry. This case was addressed with
orthognathic surgery (modified BSSO and genioplasty)
Initial (A–C) facial and
(D–I) intraoral photos.
A 21-year-old female
patient presented with
a Class III, long face
profile with facial
asymmetry.
She showed Class III
denture, deviation of
lower dental midline,
retroclination of lower
incisors, and anterior
crowding.

81. Cephalometric template
analysis (CDS analysis)
revealed that her
mandible is extremely
large, with retroclination
of lower incisors. She
was
a good candidate for
surgery. A, A point; ANB,
A point nasion B point; B,
B point.
1. CDS analysis
2. McNamara
analysis (A: 0 B:
3.0)
3. ANB (2.0)
4. Wits appraisal
(14.0)
5. Harvold
analysis (45.0)
Initial (A–C) facial and (D–I) intraoral
photos. A 21-year-old female patient
presented with a Class III, long face
profile with facial asymmetry.
She showed Class III denture, deviation
of lower dental midline, retroclination of
lower incisors, and anterior crowding.
G

82. A, The treatment goal was established and (B) the
amount of mandibular setback and tooth movement
were predicted. Since the patient had
a chin deformity, genioplasty was recommended in
addition to modified bilateral sagittal split osteotomy
(BSSO).
Initial (A–C) facial and (D–I)
intraoral photos. A 21-year-old
female patient presented with a
Class III, long face profile with
facial asymmetry.
She showed Class III denture,
deviation of lower dental midline,
retroclination of lower incisors,
and anterior crowding.

83. Orthognathic surgery. A–C, After extracting all of the patient’s third molars,
brackets and passive surgical hooks were bonded. D, The patient
then underwent modified bilateral sagittal split osteotomy (BSSO) and genioplasty.
Immediately after surgery she showed a Class II open bite with the surgical
splint in place. E, Two Y-type mini-plates were placed at the zygomatic buttress. F,
Two L-type mini-plates were fixed at the canine regions of the
mandibular body.

84. Postsurgical orthodontics. Class II
open bite and anterior crowding were
gradually but radically improved and
eventually corrected to a Class
I acceptable occlusion. Wires
consequence as follows. A,
Seventeen days: Maxilla (Mx) 0.016-
inch × 0.022-inch CNA, mandible (Mn)
0.016-inch nickeL titanium
(Ni-Ti), distalization Mx posteriors,
occlusal splint. B, Three months:
discontinued use of occlusal splint;
3.6 months: Mx 0.016-inch × 0.022-
inch
stainless steel, distalization Mx
posteriors 0.016-inch Ni-Ti
(decompensation of Mn incisors). C,
At 5.7 months: Mx 0.018-inch Ni-Ti,
leveling, distalization
completed, Mn continued leveling. D,
At 9.8 months: Mx and Mn 0.016-inch
× 0.022-inch stainless steel, occlusal
equilibrium.

85. A–C, Facial and (D–I) intraoral photos at debonding. The patient’s
orthodontic problems were corrected significantly without bicuspid
extraction.

86. Cephalometric superimposition of scans obtained initially and at debonding. With the
application of orthognathic surgery with modified
bilateral sagittal split osteotomy (BSSO) and genioplasty and skeletal anchorage
system (SAS) for postsurgical orthodontics, the patient’s complex threedimensional
dentofacial deformities were significantly improved by the course of treatment.

87. CASE REPORT 2
The patient presented with a long face, Class III
relationship with open bite. This case was
addressed with Le Fort I osteotomy, modified
BSSO, and genioplasty. Postsurgical orthodontics
involved SAS, without bicuspid extraction.
Initial (A–C) facial and
(D–I) intraoral photos.
An 18-year-old female
patient presented with a
long face, Class III
relationship and
open bite. Patient
complaints included
skewed teeth,
mandibular protrusion,
facial asymmetry, and a
gummy smile.

88. Cephalometric template analysis (CDS analysis) exhibited long face syndrome.
Mandibular excess was also obvious when plotted against
the standard. As shown in the patient example that runs throughout the chapter, generally
mild to moderate vertical maxillary excess is successfully
treated with one-jaw surgery and skeletal anchorage system (SAS) mechanics. This
patient’s long face and severe gummy smile indicated that two-jaw
surgery was necessary. A, A point; ANB, A point nasion B point; B, B point.
1. CDS analysis
2. McNamara analysis
(A: 2.0 B: 4.0)
3. ANB (0.5)
4. Wits appraisal
(12.5)
5. Harvold analysis
(45.5)

89. Treatment goals. Patient needed 10 mm of average mandibular setback, 5 mm maxillary
impaction, and reduction of chin height with
genioplasty. Her occlusion relationship changed from Class III to Class II with open
bite. A, Prediction of treatment goal including the dental and
surgical movements. The patient needed a two-jaw surgery of maxillary impaction,
mandibular setback, and a genioplasty to enhance the vertical
dimension and eliminate the gummy smile appearance. B, Model surgery simulation of
the planned surgical movement. Based on the final jaw position,
an acrylic splint is fabricated to maintain the transitional occlusion.
Maxillary
impaction
Mandibular
setback
Genioplasty

90. Orthognathic surgery. Patient underwent two-jaw surgery: Le Fort I osteotomy, modified
bilateral sagittal split osteotomy (BSSO), and
genioplasty. Occlusion right after surgery with the splint and training elastics in place: A,
Right lateral view; B, Occlusal view; C, Left lateral view;
D, Panoramic radiograph showing the surgical procedures and rigid fixation used and the
skeletal anchorage mini-plates implanted. During surgery
(E) two I-type mini-plates were placed in the zygomatic buttress and (F) L-type mini-plates
were placed in the mandible.

91. Postsurgical orthodontics. The principal skeletal anchorage system (SAS) mechanics used
in this case were intrusion and distalization
of the upper posteriors and mesialization of the lower dentition. The sequence was as
follows. A, Eight days: 0.016-inch nickel-titanium (Ni-Ti), surgical
splint, intrusion and distalization of maxillary (Mx) posteriors. B, At 3.3 months: 0.016-inch ×
0.022-inch stainless steel, Mx contraction, protraction
of mandibular (Mn) dentition. C, At 5.6 months: 0.017-inch × 0.025-inch stainless steel ideal
arches. D, At 9.2 months: occlusal equilibrium.

92. A–C, Facial and (D–I) intraoral photos at
debonding. The patient’s skeletal and
orthodontic problems were corrected
significantly by
two-jaw surgery and skeletal anchorage
system (SAS), without bicuspid extraction.
Initial (A–C) facial and (D–I) intraoral
photos. An 18-year-old female patient
presented with a long face, Class III
relationship and
open bite. Patient complaints included
skewed teeth, mandibular protrusion,
facial asymmetry, and a gummy smile

93. References:
1-
2-