Used in the right conditions, SFOA is highly successful and has a positive impact on the patients psychosocial status.A combined orthodontic and orthognathic surgery approach is accepted as the standard of care for patients who have a severe skeletal jaw discrepancy with facial asymmetry. But some disadvantages have been recognized. One drawback is the long presurgical treatment time that typically worsens facial appearance and exacerbates the malocclusion. In some countries, these disadvantages have caused patients to seek plastic surgeons who are willing to perform orthognathic surgeries without collaboration with orthodontists or consideration for the final occlusion. Recently, to address patient demand and satisfaction, the surgery-first approach was introduced to overcome some disadvantages associated with the conventional surgical orthodontic approach.1991-Brachvogel et al. suggested the potential advantages of a surgery-first approach. In that article the advantages of post-surgical orthodontics are outlined as follows: 1) Orthodontic movement does not interfere with compensatory biological responses. 2) Dental movements can be based on an already corrected skeletal pattern. 3) Some surgical relapse can be managed during treatment. 2009: Nagasaka et al., popularized SFOA54. Nagasaka et al1 were among the first to actually carry out SFOA using miniplates for post-surgical orthodontic treatment The 2011 symposium presented the surgery‑first approach and created broader interest in the complete elimination of time‑consuming preoperative orthodontic treatment

1. Surgery First
Orthognathic Approach
Dr.Lekshmi G Vijayan
2nd year PG

2. Contents
• Introduction
• Indication
• Brief history of surgical orthodontics
• General guidelines of surgery first approach
• Specific Guidance
• Regional Acceleratory Phenomenon
• Classification
• Treatment planning consideration
• Protocol in SFOA
• Use of skeletal anchorage in conjunction with surgery first approach
• Potential problems & complications
• Stability
• Conclusion
• References

3. Introduction
• A combined orthodontic and orthognathic surgery approach is
accepted as the standard of care for patients who have a severe
skeletal jaw discrepancy with facial asymmetry.
• But some disadvantages have been recognized.
• One drawback is the long presurgical treatment time that typically
worsens facial appearance and exacerbates the malocclusion.
Hyeon-Shik Hwang , Min-Hee Oh, Hee-Kyun Oh, Heesoo Oh. Surgery-first approach in correcting skeletal Class III malocclusion
with mandibular asymmetry. Am J Orthod Dentofacial Orthop 2017;152:255-67

4. • In some countries, these disadvantages have caused patients to seek
plastic surgeons who are willing to perform orthognathic surgeries
without collaboration with orthodontists or consideration for the
final occlusion.
• Recently, to address patient demand and satisfaction, the surgery-
first approach was introduced to overcome some disadvantages
associated with the conventional surgical orthodontic approach.
Hyeon-Shik Hwang , Min-Hee Oh, Hee-Kyun Oh, Heesoo Oh. Surgery-first approach in correcting skeletal Class III malocclusion
with mandibular asymmetry. Am J Orthod Dentofacial Orthop 2017;152:255-67

5. Various Approaches

6. Jeong Hwan Kim, Niloufar Nouri Mahdavie and Carla A. Evans. Guidelines for “Surgery First” Orthodontic Treatment

7. Conventional orthognathic surgery
3 steps
pre-operative orthodontic treatment
orthognathic surgery
post-operative orthodontic treatment

8. Objectives positioning of the
incisors in ideal
positions,
establishment of good
teeth inclination, and
elimination of tooth-
size discrepancies so
as to permit class I
canine and molar
relationships
temporary anchorage devices,
such as orthodontic mini-screws,
and strategic orthodontic
extractions may be used for this
dental decompensation.
retracting the maxillary
incisors and protracting the
mandibular incisors are
often required in skeletal
class III malocclusion
Preoperative orthodontic treatment
• Leveling and alignment of dental arches to eliminate
any occlusal interference at surgery
• Removal of all dental compensations to maximize
optimal surgical repositioning of the jaw.

9. Objectives
Postoperative orthodontic treatment
 Stabilization of the occlusion after surgery
 Additional leveling and alignment of the dental arch that is
not completed during pre-operative orthodontic treatment
 Coordinating both dental arches and sometimes inducing
dental compensation depending on the postoperative skeletal
relapse that may occur.
 Settling the teeth into better interdigitation.
Choi et al. Current status of the surgery-first approach (part I): concepts and orthodontic protocols. Plast Reconstr Surg. (2019)
41:10

10. Challenges Associated With Conventional Orthognathic
Surgery Cases
Long treatment times of 7-47 months.
Increased risk of enamel decalcification.
Gingival recession and root resorption.
Esthetic and functional drawbacks during the presurgical orthodontic
treatment.
S. Zingler et al Surgery-first approach in orthognathic surgery: Psychological and biological aspects – A prospective cohort
study.Journal of Cranio-Maxillo-Facial Surgery 45 (2017) 1293e1301.

11. • Primary problem- direction of pre-surgical orthodontic treatment is
opposite to that of natural dental compensation.
• Pre-surgical orthodontic movement for dental decompensation
requires time to overcome the natural compensation forces.
Jeong et al .Can a surgery-first orthognathic approach reduce the total treatment time ?. (Int. J. Oral Maxillofac. Surg. 2017; 46:
473–482)

12. History
• The first orthognathic surgery procedure was performed by Simon Hullihen
in 1848
Simon Hullihen described a procedure for the correction of mandibular dentoalveolar
protrusion in the American Journal of Dental Science in January 1849 .Technically,
this was a bilateral bicuspid region wedge ostectomy to “set back” the anterior
mandibular dentoalveolar segment

13. • J.B. Caldwell and G.S. Letterman In 1954, devised a vertical osteotomy of
the ascending ramus that involved the decortication and perforation of the
fragments and then the splitting of the medial and lateral cortices of the
ramus to allow for setback of the mandible followed by direct wire fixation
.
Jeffery c posnick.orthognathic surgery principles and practice

14. • In 1957, Trauner and Obwegeser introduced sagittal splitting ramus osteotomy, which
marked the beginning of the modern era of orthognathic surgery.
• Obwegeser was also the first to develop LeFort I osteotomy to move the maxilla in all
three dimensions, reporting a large series of maxillary osteotomy cases in 1969.
photograph of Hugo L. Obwegeser.

15. • As the first orthognathic surgery was done without preoperative
orthodontics , the history of the surgery-first method may be the same as the
history of orthognathic surgery.
• However, the current concept of surgery first is very different from the
previous orthognathic surgery without orthodontic treatment

16. • 1944-Dingman reported cases receiving surgery before orthodontics .
• 1959- Skaggs suggested that patients with minor dentition problems may
receive surgery before orthodontic treatment.
• 1988- Behrman and Behrman proposed a concept similar to RAP. But was a
conceptual suggestion.
Choi et al. Current status of the surgery-first approach (part I): concepts and orthodontic protocols. Maxillofacial Plastic and
Reconstructive Surgery (2019) 41:10

17. 1991-Brachvogel et al. suggested the potential advantages of a surgery-first
approach.
In that article the advantages of post-surgical orthodontics are outlined as
follows:
1) Orthodontic movement does not interfere with compensatory biological
responses.
2) Dental movements can be based on an already corrected skeletal pattern.
3) Some surgical relapse can be managed during treatment.
Kim, JH.; Mahdavie, NN.; Evans, CA. Guidelines for ‘surgery first’ orthodontic treatment. In: Bourzgui F, editor. Orthodontics-
basic aspects and clinical considerations. Rijeka: InTech; 2012. Available from: http://www.intechopen.com/books

18. • In 2007 Dr.William Bell commented that orthognathic surgery was
too complicated, too invasive, too time-consuming, too expensive,
and too unpredictable, establishing the Symposium of “Paradigm
Shifts in Orthognathic Surgery” with his colleagues from the
University of Texas South western Medical Center.
• Aim was to facilitate the provision of orthognathic surgery in more
efficient, affordable, predictable, and convenient ways, thus
improving the quality of care.
Uribe F, Janakiraman N, Shafer D, Nanda R. Three-dimensional cone-beam computed tomography-based virtual treatment
planning and fabrication of a surgical splint for asymmetric patients: surgery first approach. Am J Orthod Dentofacial
Orthop 2013;144:748-58.

19. • 2009: Nagasaka et al., popularized SFOA54. Nagasaka et al1
were among the first to actually carry out SFOA using
miniplates for post-surgical orthodontic treatment
• The 2011 symposium presented the surgery-first approach and
created broader interest in the complete elimination of
time-consuming preoperative orthodontic treatment
Choi et al. Current status of the surgery-first approach (part I): concepts and orthodontic protocols. Plast ReconstrSurg. (2019)
41:10

20. • The group of Sugawara and Nanda published a series of case reports using a
SFA approach to correct skeletal Class III and skeletal Class II malocclusion and
dentofacial asymmetry.
• The results demonstrated entirely acceptable facial esthetics and dental
occlusion, with total treatment time of less than 12 months
Dr. Sugawara Dr. Nanda

21. Indications
The criteria that are suggested for Surgery First Approach are:
• Well-aligned to mild crowding.
• Flat to mild curve of Spee.
• Normal to mild proclination/ retroclination of incisors.
• Minimal transverse discrepancy.
.
Even though, the surgery-first technique can be applied to Class II as well as
Class III malocclusions, the majority of cases treated using this approach have
been cases with Class III malocclusion meeting the above criteria.

22. (The surgery-first accelerated orthognathic
surgery is best indicated in cases with well-
aligned to mildly crowded anterior teeth, a
flat to mild curve of Spee, and normal to
mildly proclined/retroclined incisor
inclination.15)
Liou et al. Surgery-First Accelerated Orthognathic Surgery. J
Oral Maxillofac Surg 2011.

23. Favourable And Unfavourable Cases For SFOA
Some unfavorable cases may be
considered for the surgery-first
approach. However, much more
sophisticated treatment plan is
required for unfavorable cases.)

24. Classification
Styles of surgery first approach
• Orthodontically driven style /Sendai approach
• Surgically driven style.
1.Kim JY, Jung HD, Kim SY, Park HS, Jung YS. Postoperative stability for surgery-first approach using intraoral vertical
ramus osteotomy: 12 month follow-up. Br J Oral Maxillofac Surg. 2014 July;52(6):539-44. 18.
2.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 July;44(7):429-38

25. • Surgically driven style: When the surgical treatment is utilized not only for
correction of skeletal problem but also for the dental problem.
• Orthodontically driven style : corrects the jaw deformity by surgery and the
dental deformity via orthodontics. Recommended in 2003 at Tohoku University
in Sendai city of Japan

26. Orthodontically driven style Surgically driven style.
solve skeletal problems with OGS
and dental problems using SAS
solve both skeletal and dental
problems using OGS
Most jaw deformities are
indications
except for a few specific types of
cases
Indications
1) Crowding: no~mild
2) Curve of Spee: no~mild
3) U1 and L1: normal~mild
4) Asymmetry: no~mild
Occlusion after OGS should be
setup to
reveal the true extent of
decompensation based on
ceph prediction
Occlusion after OGS should be
setup
for “a treatable Class I
malocclusion”
with tripod occlusal contact
The use of the skeletal anchorage
system
using miniplates or miniscrews is
indispensable in the postsurgical
orthodontics of SF
Since skeletal and dental problems
are
solved surgically, the application of
TADs
is not necessarily required

28. Differences Between The Traditional Orthodontics-first And Surgery-
first Orthognathic Approaches

29. Advantages Over The Conventional Approach
• Early correction of soft tissue problems.
• Minimize serious psychosocial difficulties encountered by patients.
• Entire treatment period is shortened to 1 to 1.5 years or less.
• Phenomenon of RAP reduces the difficulty and treatment time of orthodontic
management.
• Compensation of surgical error or skeletal relapse is possible later
• Earlier resolution of temporomandibular disorders and sleep disordered
breathing
Jeong et al.Can a surgery-first orthognathic approach reduce the total treatment time ? Int. J. Oral
Maxillofac. Surg. 2017; 46: 473–482

30. 1.Prevention of Soft-tissue Profile Worsening in Surgery first Orthodontics
• Decompensation in the first stage of the conventional approach works
against all of nature’s compensatory mechanisms
• Surgical procedure is performed prior, the hard- and soft-tissue imbalance is corrected;
thus, the alignment of teeth is done easily without the need to struggle with the
biological restraints
Profile worsening in
conventionalprocedure

31. 2.Minimize serious psychosocial difficulties encountered by
patients.
• Undergoing surgical correction addresses the chief complaint
of the patient at the very start of therapy
• Patients have the possibility to select the timing of surgery to
accommodate for the postsurgical recovery period.

32. 3.The reduction in duration of treatment
Two major factors:
1.The correction of the hard- and soft-tissue disharmony before initiating
tooth movement.
2. The regional acceleratory phenomenon (RAP).

33. Total treatment time
• The total treatment duration for the orthognathic approach averages 18 to 36
months.
• The duration of pre-surgical orthodontic treatment is a key factor, because the
postoperative treatment duration typically ranges from 6 to 12 months.
Jeong et al. Can a surgery-first orthognathic approach reduce the total treatment time ?Int. J. Oral Maxillofac. Surg. 2017;
46: 473–482

34. Total treatment time depends on
Host factors
1. extent of dental
compensation
2.age
3.patient’s co-
operation
Surgical factors
1.Amount of setback
or
advancement,fixation
method,andmuscle
adaptation

35. The total treatment period: surgery-first orthognathic surgery compared with the traditional orthodontics-first method; tooth
extraction group (red) and non-extraction group (blue)
The surgery-first approach for
orthognathic surgery can accelerate
orthodontic treatment and reduce
the total duration of treatment
needed to correct dentofacial
deformities when tooth extraction is
not needed
Jeong et al. Can a surgery-first orthognathic approach reduce the total treatment time ?(Int. J. Oral Maxillofac. Surg. 2017; 46: 473–482)

36. 4.Reduced treatment time in surgery-first approach: regional acceleratory
phenomenon
Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: Postoperative
rapid orthodontic tooth movement. J Oral Maxillofac Surg 2011; 69: 781-5.

37. Regional acceleratory phenomenon
• The regional acceleratory phenomenon (RAP)
was well described by Harold Frost in 1989
• After an osteotomy, bone remodeling around
the healing tissue facilitates the healing
process.
• This regional acceleratory phenomenon can be
utilized by the orthodontist following
orthognathic surgery to accelerate tooth
movement

38. • Serum alkaline phosphatase(osteoblastic activity) and C-terminal
telopeptide (osteoclastic )of type I collagen are two bone markers
which have are studied for RAP.
• The results of one such study show that orthognathic surgery
triggers 3 to 4 months of higher osteoclastic activities and metabolic
changes in the dentoalveolus.
• RAP shows peak activity in 1 to 2months after surgery
.
Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: Postoperative rapid
orthodontic tooth movement. J Oral Maxillofac Surg 2011; 69: 781-5

39. 5.Compensation of surgical error or skeletal relapse is possible later
• If a surgical error or skeletal relapse occurs, compensation can be made
with skeletal anchorage system
• In conventional treatment, the decompensation is completed before surgery,
it is difficult or impossible to recover from surgical error during postsurgical
orthodontic treatment.

40. 6. Early resolution of temporomandibular disorders and sleep disordered breathing
• Significant number of temporomandibular disorder (TMD) symptom resolution along
with excellent results with the surgical procedures of patients with mandibular
prognathism using SFA have been reported.
• Early advancement procedures help immediately increasing the dimension of the
upper airway. Hence resolution of obstructive sleep apnea
Park KR, Kim SY, Park HS, Jung YS. Surgery-first approach on patients with temporomandibular
joint disease by intraoral vertical ramus osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol 2013
Dec;116(6):e429-e436.

41. Protocol in SFOA
• Preoperative procedures
• Surgical procedure
• Post-surgical procedure

42. Preoperative procedures
• Timing of bonding in SFOA
• Stabilizing/ Initial arch wires in SFOA
• Splints in SFOA
• Laboratory procedures

43. Timing of bonding in SFOA
• Sugawara and Nagasaka recommended that fixed orthodontic
appliances should be placed just before surgery even when using a
surgery first approach.
• But the problem is, when brackets are attached immediately before
surgery the bond strength of bracket to teeth might be weak and fail
to resist the force of intermaxillary fixation.

44. • Chung ChihYu Villegas recommended the brackets should be placed 1 week
before orthognathic surgery.
• Ellen Wen Ching recommended 1 month before surgery
If these are not placed before surgery, placement in the immediate postoperative period is often very
difficult for the patients because of swelling, discomfort, and limited mouth opening during this
time.
1.Yu CC, Chen PH, Liou EJ, Huang CS, Chen YR. A Surgery-first Approach in surgical-orthodontic treatment of mandibular
prognathism – a case report. Chang Gung Med J. 2010 Nov-Dec;33(6):699-705.
2.Villegas C, Uribe F, Sugawara J, Nanda R. Expedited correction of significant dentofacial asymmetry using a “surgery first”
approach. J Clin Orthod. 2010 Feb;44(2):97-103; 105.

45. The incidence of bracket failure (missing or loosening) has been reported to be 16% in patients
who had orthodontic brackets used for MMF during conventional orthognathic surgery.
• Since the SFA involves more two-jaw surgeries and orthodontic brackets are not
usually placed with strong surgical archwires, the brackets and wires in the SFA
frequently cannot bear or distribute the tightening stress during MMF.
• The potential risk of bracket failure might be higher than that in the
conventional approach.
• Better to apply additional screws for MMF rather than relying on the brackets,
especially for the SFA.
Tae-Geon Kwon,Michael D Han.Current status of surgery first approach (part II): precautions and complications .Maxillofacial
Plastic and Reconstructive Surgery . (2019) 41:23

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

47. Stabilizing/ Initial arch wires in SFOA
• Leveling and aligning have not yet been performed in SFOA which
makes it very difficult to place the wire.
• Most authors used stabilizing wires before surgery. Some used NiTi
wires and some used stainless steel wires.

48. • Liou et al did not place any orthodontic archwires before surgery.
• Ching et al used 0.016x0.022” superelastic NiTi wire.
• Carlos et al have opted to use 0.16”X0.16” nickel-titanium wires at
time of surgery.
• The use of nickel-titanium wires translates into immediate tooth
movement after surgery which can be an advantage.
• However, in doing so, the orthodontist loses the opportunity to
observe the stability of the surgical correction prior to starting the
tooth movement
1.Liou EJ, Chen PH,Wang YC, Yu CC,Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: postoperative rapid
orthodontic tooth movement. J Oral Maxillofac Surg 2011;69:781-5.
2.Choi JY, Song KG, Baek SH. Virtual model surgery and wafer fabrication for orthognathic surgery. Int J Oral Maxillofac Surg.
2009 Dec;38(12):1306-10.

49. • Sugawara and Nagasaka preferred 0.18”x0.25” SS wires and
0.19”x0.26” SS wires in 0.022 slot are adapted to all teeth for
preventing any tooth movement.
• Full slot withstands the forces resulting from intermaxillary
fixation.
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 July;44(7):429-38

50. • Either brackets have hooks or brass wire (lugs) are soldered to the arch
wire for wiring fixation, Kobayashi hooks can also be used. Occasionally,
intermaxillary screws may be required.

51. Other options for presurgical preparation for the SFA according to the
literature
1. Preoperative placement of surgical arch bar, without orthodontic
archwire,
2. Preoperative placement of anchor screws, without orthodontic
archwire
3. Preoperative placement of light round or light rectangular wire
(with/ without screws or anchor plates)
4. Preoperative placement of conventional passive, rectangular wires
attached with surgical hook (with/without anchor screws).

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

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

54. Splints in SFOA:
• The use of surgical splint during and after surgery also varies
between different orthodontists.
• While some advocate the use of the splint only during surgery,
other groups have advocated its use anywhere between one to four
weeks after surgery

55. • Nagasaka et al have used removable Gelb–type splints post operatively. Their
preference is to leave the splint in for about 4 to 6 weeks after surgery and if
an open bite is observed, to use elastic between the splint and the mini-screws
or to leave the splint for a longer period of time.

56. • Sugawara et al modified the surgical splint into a removable
maxillary occlusal splint, which was used to stabilize the jaw
position and masticatory function.
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 July;44(7):429-38

57. Protocol Variations

58. Laboratory procedures:
• Pre-surgical procedure with the dental model is the most
important step in the surgery-first approach
• “Set-up models” are used to predict and simulate dental positions
and arch coordination for decision on surgical jaw movement.
• Liou et al suggested to set-up model surgery in proper molar
relationships with a positive overbite that is opposite to the
conventional approach which uses decompensated incisors as the
guide to predict the final occlusion

59. STEPS
Standard model
mounting
Before the procedure,
the teeth that have
adapted to the skeletal
discrepancy are
simulated and
reorganized into their
predicted location,
similar to real pre-
surgical orthodontic
treatment
Simulation of
actual
orthognathic
surgery is then
performed.
At this point, if the position
of the teeth is reverted to the
condition before presurgical
orthodontic treatment, this
model will reflect the
possible condition following
orthognathic surgery
without pre-surgical
orthodontics.
Intermediate and final wafers for orthognathic surgery with the surgery-first approach
can be made on the basis of the final dental model

60. For the model surgery, the maxilla and mandible are set up in a
proper molar relationship and with a positive overbite.
The molar relationship could be
• Class I in cases of nonextraction or bimaxillary first premolar
extraction
• Class III in cases of lower first premolar extraction
• Class II in cases of maxillary first premolar extraction.
Once the molar relationship has been established, the overjet should
also have been determined.
Liou EJ, ChenPH,Wang YC,Yu CC, Huang CS,Chen YR.Surgery-first accelerated orthognathic
surgery: Orthodontic guidelines and setup for model surgery.J OralMaxillofac Surg
2011;69:771-80.

61. Virtual Surgical Planning And Splintless Surgery
• The demand for accuracy has driven the development of computer-
assisted planning and splint fabrication.
• Computer-aided orthognathic surgery can be divided into 3 basic
categories:
 Computer aided preoperative planning
 Intraoperative navigation
 Intraoperative computed tomography or MRI.
• Very complex dentofacial deformities especially the asymmetric cases
can be planned using computer-assisted surgical simulation and
splints can be virtually fabricated

62. 3D virtual planning LeFort I osteotomy with maxillary advancement, unilateral
impaction on the right, bilateral split sagittal osteotomy with unilateral setback (right
side), and lateral sliding genioplasty in patient with classIII malocclussion treated with
surgery first approach

63. Computer-manufactured intermediate and final splints
.
Flavio Uribe, Nandakumar Janakiraman,David Shafer, Ravindra Nanda Three-dimensional cone-beam computed tomography-based virtual treatment
planning and fabrication of a surgical splint for asymmetric patients: Surgery first approach. Am J Orthod Dentofacial Orthop 2013;144:748-58)

64. Treatment Planning Considerations
• The molar relationship can be utilized as a starting point to come
up with a temporary occlusion.
• The inclination of upper incisors is important in determining the
need for possible extractions. If the upper incisor to occlusal plane
angulation is <53-55°, extraction must be considered.
Park KR,Kim SY,Park HS,Jung YS.Surgery-first approach on patients with temporomandibular joint disease by intraoral vertical ramus
osteotomy.Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:e429-36

65. • The midlines must be coincident or close to it after surgery,
and proper buccal overjet must be established bilaterally
• Depending on the degree of discrepancy between the two
arches, plan for segmental osteotomies in more severe cases
or possibly plan on resolving the issue post-surgically by arch
coordination and elastics.

66. • Most challenging and time consuming step is the prediction of
the final occlusion based on the current position of teeth.
• The term intended transitional malocclusion is used to describe
the occlusion that is used to fabricate the surgical splint and
surgeon's guide during surgery. At least a three-point contact
must be established between the upper and lower models when
deciding ITM.

67. Careful planning is the key to the success of any
orthognathic surgery case especially when the surgical
procedure is to be performed prior to orthodontic
treatment.
• Treatment considerations in skeletal class II in SFOA
• Treatment considerations in skeletal class III in SFOA
Sharma VK, Yadav K, Tandon P. An overview of surgery-first approach: Recent advances in orthognathic surgery. J
Orthodont Sci 2015;4:9-12.

68. Treatment considerations in skeletal class II
in SFOA
• Skeletal class II malocclusion typically involves proclination of
mandibular incisors and upright/mild proclination of maxillary
incisors.
• SFOA may be particularly beneficial for a class II patient with a
retrusive mandible.
• Immediately after surgery the Class II malocclusion becomes a
super class I or Class III relationship following mandibular
advancement, with an edge-to-edge incisor relationship or
bimaxillary dentoalveolar protrusion

69. • This situation therefore requires the use of class III
orthodontic mechanics or it can also be corrected by
extracting all first premolars followed by retraction as in
class I bimaxillary protrusion cases.
• Thus the resulting improvement in the tone of the lower
lip and tongue increases the forces acting on the incisors
in both arches.

70. • In class II division 2 cases it is difficult to perform SFOA as
there is a less overjet.
• In such cases surgery can be performed after uprighting the
upper anteriors and after obtaining the sufficient overjet for the
advancement of mandible or surgery can also be performed
directly without presurgical orthodontics thereby getting reverse
overjet, which can be corrected post-surgically.

71. • In these cases, the lower incisors are usually crowded and retroclined
while the maxillary incisors are commonly flared out.
• when surgery is performed first, a class III malocclusion always
become a class II relationship immediately after mandibular setback
which should be maintained with surgical splint and requires class II
orthodontic mechanics after surgery and adjustment of the anterior
teeth can be managed postoperatively.
Treatment considerations in skeletal class III
in SFOA

72. Specific guidelines
Anteroposterior and Vertical Decompensation in Class III
Cases
1. For proclined maxillary incisors in a Class III case
Anteroposterior decompensation achieved by
• Extraction of the maxillary first premolars & Anterior
segmental osteotomy
• Clockwise rotation of the maxilla by Le Fort I osteotomy to
upright the upper incisor inclination

73. (A-F) Surgery-first accelerated orthognathic
surgery in Class III patient with proclined
maxillary incisors. The surgery included Le
Fort I osteotomy, maxillary anterior segmental
osteotomy, bilateral sagittal split of mandible, and
genioplasty. (G-L) The anteroposterior
decompensation for the proclined maxillary
incisors was achieved by extraction of the
maxillary first premolars and anterior segmental
osteotomy to upright the proclined maxillary
incisors.
.
Liou et al. Surgery-First Accelerated Orthognathic
Surgery. J Oral Maxillofac Surg 2011

74. A-F) Another approach for the surgery-
first accelerated orthognathic surgery
in a Class III patient with proclined
maxillary incisors. The
surgery included Le Fort I osteotomy
and bilateral sagittal split of the
mandible. (G-L) The anteroposterior
decompensation for the proclined
maxillary
incisors was achieved by clockwise
rotation of the maxilla by Le Fort I
osteotomy to upright the upper incisor
inclination.
.
Liou et al. Surgery-First Accelerated
Orthognathic Surgery. J Oral Maxillofac
Surg 2011

75. 2. Moderately retroclined and crowded lower incisors in a
Class III case
• Achieved by setting up the molars in a Class I
relationship with an excessive incisor overjet
• Then the lower incisors could be aligned postoperatively
to obtain a normal overjet.

76. (A-F) Surgery-first accelerated orthognathic
surgery in Class III patient with anterior open bite
and moderate retroclined and
crowded lower incisors. The surgery included Le
Fort I osteotomy, maxillary anterior segmental
osteotomy, bilateral sagittal split of the
mandible, and genioplasty. (G-I) The occlusion was
set up in a Class I molar relationship and with
excessive incisor overjet. (J-O) The
retroclined lower incisors and excessive overjet
were then decompensated and aligned
postoperatively to obtain a normal incisor
inclination and overjet.
Liou et al. Surgery-First Accelerated Orthognathic
Surgery. J Oral Maxillofac Surg 2011.

77. 3. Severely retroclined and crowded lower incisors in a
Class III case
• Extraction of the lower first premolars and
• Anterior segmental osteotomy, setting up the molars in a Class III
molar relationship with an excessive incisor overjet, and then
• The lower incisors could be aligned postoperatively to obtain a
normal overjet.

78. (A-F) Surgery-first accelerated orthognathic surgery in Class
III patient with severe anterior open bite and retroclined and
crowded lower
incisors. The surgery included Le Fort I osteotomy, bilateral
sagittal split of the mandible, and mandibular anterior
segmental osteotomy. (G-I) The
maxilla was rotated clockwise to upright the upper incisor
inclination, the lower first premolars were extracted and
anterior segmental osteotomy
was performed, and the occlusion was set up in a Class III
molar relationship and with excessive incisor overjet during
surgery. A chin cap was
applied to prevent the mandibular skeletal relapse in the first
3 months postoperatively. (J-Q) The retroclined lower
incisors and excessive overjet
were then decompensated and aligned postoperatively to
obtain a normal inclination and overjet.
Liou et al. Surgery-First Accelerated Orthognathic
Surgery. J Oral Maxillofac Surg 2011

79. 4.A moderate to deep mandibular curve of Spee in a Class III case
• Better leveled either preoperatively or surgically by anterior
segmental osteotomy to avoid the upward and forward rotation of the
mandible postoperatively.
• A forward and upward rotation of the mandible improves the chin
projection in the case of Class II mandibular retrognathism.
• A chin cap could be applied to prevent mandibular skeletal relapse in
the first 3 months postoperatively

80. Anteroposterior and Vertical Decompensation in
Class II Cases
For a moderate to deep mandibular curve of Spee and proclined
lower Incisors in Class II mandibular retrognathism
• The anterior segment of the mandible could be levelled and
intruded surgically through anterior segmental osteotomy so that
the mandible could be advanced properly.

81. • Alternatively, the mandible could be surgically advanced
to an edge-to-edge incisor relationship and without
occlusal contact in the posterior teeth
• And then postoperatively, the mandibular anterior teeth
could be orthodontically intruded and hence that the
mandible rotates upward and forward for posterior
occlusal contact and a better chin projection.

82. A-E) Surgery-first accelerated
orthognathic surgery in Class II
mandibular retrognathism patient with
deep mandibular curve of Spee and
proclined lower incisors. The surgery
included bilateral sagittal split of the
mandible and genioplasty. (F-K) The
mandible was
advanced to an edge-to-edge incisor
relationship without occlusal contact in
the posterior teeth during surgery. The
mandibular anterior teeth
were then orthodontically intruded
postoperatively for the posterior occlusal
contact and upward rotation of the
mandible after surgery. (L-Q)
Improvement of occlusion and facial
profile at end of treatment.
Liou et al. Surgery-First Accelerated
Orthognathic Surgery. J Oral Maxillofac
Surg 2011.

83. Transverse Arch Co-ordination
The intercanine and intermolar widths of the upper and lower dentitions are
co-ordinated either by surgery or postoperative orthodontic tooth movement.
.
• Wide maxilla with a transverse discrepancy more than a
molar width on each side - 3-piece Le Fort I osteotomy of
the maxilla.
• Wide maxilla with a transverse discrepancy less than a
molar width on each side - postoperative orthodontic
tooth movement.
• Narrow maxilla - surgically assisted rapid palatal
expansion

84. (A-C) In surgeryfirst accelerated orthognathic
surgery, it is not necessary to coordinate the arch
transverse discrepancy before surgery when the
discrepancy is less than a molar width. (D-F) The
excessive buccal overjet was solved postoperatively in
2.5 months because of the phenomenon
of postoperatively accelerated orthodontic tooth
movement.
Liou et al. Surgery-First Accelerated
Orthognathic Surgery.J Oral Maxillofac Surg 2011.

85. Postoperative procedure in SFOA
• The objectives of orthodontic treatment after surgery in the
SFOA technique are dental alignment, arch coordination, and
allow occlusal settling, that together might take another 6-12
months.
• This period can speed up orthodontic tooth movement due to
Regional Acceleratory Phenomenon

86. • Leelasinjaroen et al suggested postsurgical orthodontic treatment
could begin as early as one week to one month postoperatively.
• Kim et al suggested to wait four to six weeks.
• The surgical splint and intermaxillary fixations should be removed
for the tooth movement

87. • Nagasaka et al completed postoperative orthodontic treatment within
approximately 1 year.
• Sugawara et al removed the fixed orthodontic therapy after 9 months.
• Villegas et al removed the fixed appliances 7 months after surgery.
Treatment time was approximately 6-12 months shorter using a
surgery-first approach compared with using a conventional
orthodontics-first approach

88. Postoperative Management
• In the surgery first approach, unfavorable orthodontic movements after surgery
can accelerate the postoperative malocclusion more quickly.
• The use of orthopedic traction rather than orthodontic traction is emphasized
when using conventional light round orthodontic wires for surgery.
• Wearing and adjusting the surgical splint postoperatively is an important step
for a stable occlusion and long-term skeletal stability.
• When a significant occlusal discrepancy is anticipated after surgery, buildup of
occlusal resin to stabilize the immediate postoperative occlusion should be
strongly considered
Tae-Geon Kwon,Michael D Han.Current status of surgery first approach (part II): precautions and complications .
Maxillofacial Plastic and Reconstructive Surgery . (2019) 41:23

89. Predictability Of Surgery First Approach
• Conventional orthodontics-first approach, presurgical planning can
be performed twice: during the preorthodontic (initial surgical
treatment objective, STO) and presurgical phases (final STO).
• The surgical simulation and planning can be modified at the final
STO, based on the orthodontic changes made during that interval.
• For the surgery first approach, the initial STO is the final STO

90. • Where there is arch width discrepancy, asymmetric transverse arch, or
severe crossbite or deep bite, it is difficult to simulate the possible
orthodontic movements that can address these problems.
• Introduction of 3D virtual orthodontic setup technology cannot
completely solve the potential problems.
• There is a lack of discussion on predictions regarding occlusion, and
soft tissue prediction in the peri-nasal or lip areas still requires further
development .
Tae-Geon Kwon,Michael D Han.Current status of surgery first approach (part II): precautions and
complications .Maxillofacial Plastic and Reconstructive Surgery . (2019) 41:23

91. More surgical intervention in surgery first approach than
conventional approach?
• 84.7% of the reported surgery first approach cases were two-jaw
surgery .
• Skeletal class III deformities, it is mandatory to correct the
protruded maxillary incisor angulation by Le Fort I posterior
impaction with or without segmental maxillary osteotomy.
• The recent development of screw or plate-anchored orthodontic
treatment can allow minimally invasive and fewer surgical
procedures

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

93. Use Of Skeletal Anchorage In Conjunction With
Surgery-first Approach
Initial Immediately after surgery At debonding after treatment using SAS
“Surgery first” mandibular setback for skeletal Class III
correction

94. • Many uncertainties remain at the time, patient is sent to
surgery.
• Temporary anchorage are utilized as a “back-up” system,
which can be used to help in postsurgical orthodontic
phase.
• These devices are anywhere from single mini-implants to
titanium plates which can be placed at the time of
surgery.

95. • Because skeletal anchorage system(SAS) mechanics can predictably
distalize the maxillary molars and protract the mandibular molars in
nongrowing patients, it is not difficult to correct Class II
malocclusions without premolar extractions
• The SAS mechanics can also be used to correct open bite, anterior
crowding, dental asymmetry, or excessive arch spacing etc

96. • When extractions or segmented osteotomies are planned, prediction
of the final occlusion is far more challenging, and placement of
mini-implants during the surgery allows for efficient mechanics
postsurgically
Tae-Geon Kwon,Michael D Han.Current status of surgery first approach (part II): precautions and complications
.Maxillofacial Plastic and Reconstructive Surgery . (2019) 41:23

97. Changes in canine and molar relationships during postsurgical orthodontic treatment,
using the SAS. A. At one and a half months after surgery. B. At four months. C. At six
months. D. At seven and a half months. E. At eight months. F. At 10 months.
Nagasaka H, Sugawara J, Kawamura H, Nanda R. "Surgery first" skeletal class III correction using the Skeletal Anchorage
System. J Clin Orthod. 2009;43:97–105.

98. POTENTIAL PROBLEMS
• Predicting the final occlusion is the hardest challenge with SFA due
to multiple dental interferences
• Cases requiring extractions are especially very difficult to plan when
performing surgery-first
• Any minor surgical error can compromise the final occlusion
• The planning process is very time consuming in contrast to the total
treatment time
• The increase in the number and complexity of osteotomy procedures
poses a greater risk to the patient.

99. Stability
• Surgery first orthognathic approach may yield poorer postoperative stability
than Conventional orthognathic approach .
An example of mandibular relapse after SFA. Pogonion
position at the immediate postoperative mark (broken arrow),
significantly moved forward after surgery with SFA (solid
arrow)without any evidence of temporomandibular joint
problems

100. • The first factor is the unstable occlusion acquired after surgery in surgery
first group, which is unfavourable to postoperative stability.
• The compressive force of the masseter muscle applied to the bone segment
is no doubt the main cause of relapse.
• However, a stable occlusion contributes to bone stability and decreases
the possibility of mandibular relapse.

101. • The second factor may lie in the mandibular autorotation
after the removal of the surgical splints or postoperative
orthodontic correction of occlusal interference

102.  The third factor is the high degree of tooth movement in the postoperative
orthodontic.
 The orthognathic surgery triggers a 3- to 4-month period of greater
osteoclastic activities and metabolic changes in the dentoalveolar region,
known as the regionally accelerated phenomenon.
 The regionally accelerated phenomenon helps us accelerate postoperative
orthodontic tooth movement, which also cause the immediate rotational
relapse as well. Mandibular protrusive relapse may happen in the initial
stage of postoperative orthodontic treatment.
HongpuWei,ZhixuLiu,JiajieZang,XudongWang.Surgery-first/early-orthognathicapproachmayyieldpoorer
postoperativestabilitythanconventionalorthodontics-firstapproach:asystematicreviewandmeta-analysis .
(OralSurgOralMedOralPatholOralRadiol2018.02.018

103. Contraindications
• Amount of decompensation required is difficult to build
into the surgical occlusion
• Severe craniofacial deformities
• Patients with severe crowding or severe vertical
&transverse discrepancies
• class II division 2 malocclusion cases with deep overbite
Although the current exclusion criteria may seem rather extensive, it
is expected that the indications for the SFA will gradually broaden as
the experience with this approach increases and current limitations
become reasonably controlled

104. Conclusion
• SFOA may yield poorer postoperative stability than a conventional
orthodontics-first approach according to the current evidence, but used in the
right conditions, it is highly successful and has a positive impact on the
patients psychosocial status.

105. • The scope of this approach has been expanding with advances in 3-dimensional
(3D) imaging technology and 3D virtual surgical simulation, the use of skeletal
anchorage systems, and better understanding of the biologic response after
surgery

106. References
1. Hyeon-Shik Hwang , Min-Hee Oh, Hee-Kyun Oh, Heesoo Oh. Surgery-first
approach in correcting skeletal Class III malocclusion with mandibular
asymmetry. Am J Orthod Dentofacial Orthop 2017;152:255-67
2. Jeong Hwan Kim, Niloufar Nouri Mahdavie and Carla A. Evans. Guidelines for
“Surgery First” Orthodontic Treatment
3. Choi et al. Current status of the surgery-first approach (part I): concepts and
orthodontic protocols. Plast Reconstr Surg. (2019) 41:10
4. S. Zingler et al Surgery-first approach in orthognathic surgery: Psychological and
biological aspects – A prospective cohort study.Journal of Cranio-Maxillo-Facial
Surgery 45 (2017) 1293e1301
5. Jeong et al .Can a surgery-first orthognathic approach reduce the total treatment
time ?. (Int. J. Oral Maxillofac. Surg. 2017; 46: 473–482

107. 5. Jeffery c posnick.orthognathic surgery principles and practice
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using intraoral vertical ramus osteotomy: 12 month follow-up. Br J Oral Maxillofac Surg. 2014
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108. 11. 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 July;44(7):429-38
12 Flavio Uribe, Nandakumar Janakiraman,David Shafer, Ravindra Nanda Three-dimensional cone-
beam computed tomography-based virtual treatment planning and fabrication of a surgical splint for
asymmetric patients: Surgery first approach. Am J Orthod Dentofacial Orthop 2013;144:748-58
13. Park KR,Kim SY,Park HS,Jung YS.Surgery-first approach on patients with temporomandibular joint
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orthognathicapproachmayyieldpoorer postoperativestabilitythanconventionalorthodontics-
firstapproach:asystematicreviewandmeta-analysis .
(OralSurgOralMedOralPatholOralRadiol2018.02.018
Nagasaka H, Sugawara J, Kawamura H, Nanda R. "Surgery first" skeletal class III correction using the
Skeletal Anchorage System. J Clin Orthod. 2009;43:97–105