sfoa orthognathic surgery

1. SURGERY-FIRST
ORTHOGNATHIC
APPROACH (SFOA)
1960
2009
OBLIVION HEURISTIC

2. CONTENTS
■ Introduction
■ Diagnosis and Treatment Planning
■ Biological Principles and Responses to SFOA
■ Biomechanical Principles of SFOA
■ Orthodontic Considerations
■ Management of Skeletal Class I Malocclusion
■ Management of Skeletal Class II Malocclusion
■ Management of Skeletal Class III Malocclusion
■ Management of Skeletal Asymmetry
■ Pre- and Post-surgery Patient Care Checklist and Patient Instruction
■ Potential Complications
■ Conclusion
■ References

3. INTRODUCTION
■ One patient two problem
■ Skeletal – jaw surgery
■ Dental – conventional orthodontic treatment
■ Jaw surgery is coming into a new era of management where patients and
practitioners both benefit.
■ It ned interest when Nagasaka et al. performed SFOA and consequently various
groups published case series and lead to a new paradigm.

4. Overview
■ 1849 – Simon Hullihen
■ 1957- Richard Trauner and Hugo
■ Jaw surgery was carried out
without presurgical orthodontics ,
which unwittingly gave rise to
surgery-first approach.
■ Factors

5. ■ Worms et al. stated that orthodontics-first concept must be rigorously employed
to all jaw surgery following the elimination of all impeding dental compensation
prior to surgery.
■ Post 1970- ‘orthodontic decompensation’ – ‘ Surgical orthodontics’
■ Dr William Bell that conventional jaw surgery is ‘too complicated, too invasive,
too-time consuming, and too unpredictable’,
■ A paradigm shift would be necessary to ensure jaw surgery to become more
efficient, affordable, predictable, and convenient with a focus on utilizing
advanced three-dimensionalimaging technology and empirical evidence to
mitigate the effects of pre-surgical orthodontic treatment.
■ Nagasaka et al

7. Diagnosis and treatment planning
■ Basis
■ Emphasis is laid on the understanding and visualizing of the post-surgery
‘transitional occlusion’.
■ Orthodontists play a pivotal role from the beginning and, together with the
surgeon,perform patient evaluation and data collection
■ Why photographs, study models, and radiographs ?
■ 3D-assisted method (3D composite modelling and stereolithography)
■ Mock surgery (paper and model surgery )

9. GNATHIC PROFILE FIELD (GPF) AND ‘RULE OF
THIRDS’

10. PAPER SURGERY
MOCK SURGERY

11. 3D Virtual Surgical Planning and 3D Splint
Fabrication

12. BIOLOGICAL PRINCIPLES AND
RESPONSES
■ HAROLD M.FROST an American orthopaedic surgeon,first described regional
acceleratory phenomenon (RAP).
■ ‘a tissue reaction to different noxious stimuli’
■ Frost proposed the existence of RAP at a fracture site causes an acceleration of
the normal repair and renewal process in both hard and soft tissue brings about
healing within a period of time.
■ Once activated leads to ‘ARF’ sequence.(activation,resorption & formation).
■ Sometimes transient osteopenia.

13. Systemic acceleratory phenomenon (SAP)
■ Mueller, Schilling, and team at the University of Heidelberg.
■ Restoration of a local defect in a rat model not only leads to a regional
acceleratory phenomenon (RAP).
■ Systemic acceleratory phenomenon (SAP) at distant sites of the skeleton.
■ SAP leads to the release of osteogenic growth peptide (OGP)
■ Stimulates proliferation of alkaline phosphatase activity that ultimately
accelerates bone repair process.

15. ■ Investigation of how chemical mediators (complement, vasoactive amines,
neuropeptide, cytokines, vascular endothelial growth factor, etc.) are influenced
by various noxious stimuli.
■ Further evaluation of molecular mechanisms underlying accelerated orthodontic
tooth movement and effects on bone, soft tissues, nervous system and
periodontium.
■ In-depth analysis of RAP side-effects and risks associated with correlation of
bone strength, fragility, and long-term characteristic evaluation of skeletal
maturation has to be done.

16. BIOMECHANICAL PRINCIPLES
■ Meticulous step-by-step approach.
■ cognizance of the dentofacial structures and their posed complexities.
I. 3D facial morphometrics
II. 3D non-contact laser scan
III. 3D cone beam computed tomography (CBCT)
IV. stereolithography,
V. 3D ultrasound holography
VI. finite element modelling,
VII. Moire topography
VIII. video imaging,
IX. contour photography

17. Six Degrees of Freedom (6DoF)
■ The maxillo-mandibular complex
(MMC) is like a rigid body with six
degrees of freedom in three-
dimensional space having
Three translation coordinate axes,
namely,
■ (1)sagittal, (2) transverse, and (3)
vertical, and
Three rotation axes
(1) pitch, (2) roll, and (3) yaw
yaw
pitch
roll

18. Orthodontic considerations
Pre surgical orthodontics
Pre-surgical preparation phase
Post surgical orthodontics

19. Pre surgical orthodontics
■ In conventional jaw surgery, there is an emphasis on
(1) arch coordination (dental expansion of the arches),
(2) alleviation of crowding (levelling and alignment),
(3) dental decompensation in the form of up righting retroclined teeth
and retraction of proclined teeth.
■ In SFOA, the pre-surgical orthodontic stage is reduced to minimal
orthodontics where brackets are bonded but minimal or no
orthodontic tooth movement is carried out.
■ The orthodontic tooth movement is carried out post-surgery.

20. Pre-surgical preparation phase
■ 1. Determination of transitional occlusion.
■ 2. Surgical splint fabrication, intermaxillary fixation.

21. 1. Determination of transitional occlusion
■ The transitional occlusion is an occlusion that is set up immediately after surgery such that the
existing malocclusion lies within the orthodontically manageable tooth movement boundary.
■ Sagittal plane : minimal crowding –
establishing positive overjet
an occlusion with three point contact
■ Transverse plane :
Intercanine and intermolar width of upper and lower dentition is maintained.
Crossbite not more than one buccal cusp width of maxillary molar.
■ Vertical plane :
For hypodivergent skeletal pattern with deep curve of Spee: edge-to-edge anterior teeth with no
occlusion in the posterior teeth such that posterior teeth can be extruded post-surgically .
For hyperdivergent skeletal pattern with anterior open bite: positive overjet with clockwise rotation
of maxilla and anticlockwise rotation of mandible to counter post-surgical relapse of open bite

22. Surgical splints fabrication
■ IMF
Different techniques to perform
intermaxillary fixation (IMF), such as
■ Direct interdental wiring,
■ IMF screws,
■ arch bars,
■ eyelet wiring,
■ cap splints.
■ Now brackets have hooks and it will be
used for fixing.

23. Post-surgery
■ Post-operative orthodontic treatment was initiated 2 months after surgery.
■ Surgery-first approach using bilateral sagittal split osteotomy (BSSO) reported
mostly shorter stabilization time and earlier initiation of post-operative
orthodontic treatment .
■ Immediate post-operative leveling of the dentition to solve dental interference
and arch compatibility.
■ Changing heavy stabilization arch wires with light/resilient working wires
immediately after surgery was suggested to shorten the post-operative
orthodontic treatment time.
■ Orthodontic treatment must start as soon as possible to take advantage of the
regional acceleratory phenomenon.

24. INDICATIONS
They are
■ (1) minimal crowdingin the
anterior teeth,
■ (2) favorable curve of Spee, and
■ (3) normal range of angle between
the basal bone to upper and lower
incisors

25. Management of skeletal class I malocclusion
■ Skeletal Class I patients requiring surgery predominantly exhibit a severe
sagittal discrepancy, either in a bimaxillary protrusion or a retrusion relationship.
■ Control of maxillary occlusal plane is the key for the successful treatment of
skeletal Class I malocclusion.

26. Case report 1
■ A 20-year-old female presented with a chief complaint of unable to see her top front teeth
when smiling. Extra-orally, she showed a concave profile, prominent chin, retrusive upper
and lower lip, and a reverse smile arc .
■ Intra-orally, she showed a Class I molar and canine relationship and mild lower anterior
crowding with overjet and overbite within normal limits
■ The objectives were classified into three main categories, and they are:
■ 1. Skeletal objectives.
■ (a) To correct the hypoplastic maxilla & retrognathic mandible.
■ (b) To correct the large chin.
■ 2. Dental objectives.
■ (a) To correct minimal crowding & to maintain the upper and lower arch Class I relationship.
■ 3. Soft tissue objectives.
■ (a) To restore facial harmony.
■ (b) To produce an aesthetically satisfactory face.

30. ■ A LeFort I osteotomy for the advancement of maxilla with clockwise rotation, and
BSSO for the advancement of the mandible, was planned, along with a
reduction genioplasty for the correction of the prominent chin.
■ All teeth were bonded, and a stainless steel ligature was tied passively in the
upper and lower arches.
■ The patient was subjected to surgery as planned. One week post-surgery extra-
oral images showed fulfilment of surgery objectives with no change in the
occlusal aspect .
■ The overall treatment time was 4 months from start to finish.
■ Treatment results: post-treatment images and radiographs showed excellent
aesthetic and occlusal results.
■ The key for successful management of skeletal deformity with Class I occlusion
is to maintain the posterior buccal occlusion; every effort should be made to
preserve the occlusion.

31. Management of skeletal class II
malocclusion
■ In order to determine the suitability of appropriate treatment planning,
it is essential to ascertain the type of skeletal Class II malocclusion
and distinguish whether the skeletal Class II pattern arose from a
single entity such as maxilla or mandible or a combination of both.
■ One must also consider if there is a dental component contributing to
the overall Class II problem.
■ Class II skeletal deformity characterization in three-dimensional space
and an effective surgical management plan to obtain stable aesthetic
and functional results.

33. Case 1
■ A 26-year-old female presented with chief complaint of small chin and sticking out
upper front teeth.
■ She had orthodontic treatment during her teenage years and expressed
dissatisfaction with the results. On examination, she showed short chin throat length,
lip incompetence, a gummy smile, concordant smile arc, missing #14, 24, and 34,
and a lower dental midline deviated to the left side by 2 mm in relation to the upper
dental midline.
■ Her upper anterior teeth were retroclined, and pharyngeal airway space was
constricted.
■ The cephalometric findings confirmed the clinical observation with SNA 77°, SNB
67°, ANB 10°, SN-MP 58°, UAFH/LAFH 42/58%, U1/SN 85°, and IMPA 87°.

35. (First and second row) Post-surgery
lateral cephalograph and intra-oral
photos showing achievement of surgery
objective.
(Third row) 1-week post-op, minor early
relapse was noted with anterior overbite
of −2 mm and overjet of 0 mm.
(Fourth row) At 8-month post-op,
midline and anterior open bites were
corrected by diagonal elastics and
anterior vertical elastics, respectively

36. Post-treatment extra- and intra-oral images

37. ■ Two-jaw surgery: Counterclockwise rotation of MMC differential LeFort I
osteotomy and BSSO.
■ For LeFort I, the pivotal point is at the anterior maxilla with superior repositioning
of the anterior maxilla and inferiorly repositioning the posterior maxilla such that
the MMC rotates in a counterclockwise direction.
■ The MMC counterclockwise rotation would upright the upper incisor angulation
and a post-surgical occlusion set up in an anterior edge-to-edge relation with the
remaining midline discrepancy that would be corrected in the post-surgical
orthodontic treatment phase .

38. Case 2
■ A 22-year-old female presented with a chief complaint of her upper front teeth
forwardly placed and difficulty in eating with her front teeth.
■ Extra-orally, she exhibited a convex profile, marked protrusion of upper lip, and
reduced lower anterior facial height. Intra-orally, she showed 100% deep bite,
Class II canine, and molar relationship.
■ CBCT scan confirmed the clinical findings with skeletal pattern being
hypodivergent and no temporomandibular joint aberrations

39. Pre-treatment intra- and extra-oral images

40. Planning is carried out such that a treatable malocclusion is established along with
mandibular advancement and counterclockwise rotation of MMC.
An edge-to-edge incisor relationship with 7-mm posterior open bite is created in the
study models.
The surgery plan is emulated with intra-oral images taken immediately post-surgery
showing actualization of model surgery

41. Images taken at 2 months post-surgery. Bilateral intrusion arches were placed in the
lower arch to intrude and upright the retroclined lower incisors.
The cantilever mechanism will extrude the posterior teeth and intrude and upright the anterior
teeth.
The aforementioned tooth movement biomechanics is beneficial in this case, as the posterior
teeth extrusion allows to close the posterior open bite and maintain the vertical height
established during surgery, and also, in the anterior segment, intrusion and uprighting of anterior
teeth will allow the mandible to further rotate in anticlockwise direction which will enhance the
chin projection and ultimately aid in improvement of recessive chin

42. Images at 6 months post-surgery. Vertical elastics were placed for settling of occlusion

43. Images taken at 8 months post-surgery showing fulfilment of treatment
objectives

44. ■ Two-jaw surgery: A two-jaw surgery was planned such that mandible was
advanced to edge-to-edge bite with the creation of posterior open bite.
■ LeFort I osteotomy with maxillary setback was planned for the correction of
maxillary
skeletal protrusion and also creation of an orthodontically treatable malocclusion

45. Case 3:
■ A 28-year-old Patient presented with a chief complaint of skewed upper front
teeth. Extra-orally, she showed convex profile, recessive chin with chin
puckering, asymmetric mandible with left side deviation, deep labial-mental fold,
and an asymmetric smile.
■ Intra-orally, there were a left-sided buccal segment buccal crossbite and heavily
restored upper and lower posterior teeth with maxillary occlusal canting.

46. Pre-treatment images showing Class II maxillary protrusion, mandibular retrognathism,and facial
asymmetry. Intra-oral images showing Class II division 1 malocclusion, left side buccal segment
scissors bite, heavy restorations of upper and lower posterior teeth.
Maxillary occlusion showed maxillary right side up occlusal cant, and mandibular occlusion showed
left side up.

47. The surgical plan included LeFort I three-piece osteotomy to decrease upper intermolar
width for the correction of left posterior segment scissors bite with extraction of bilateral upper
right and left second premolars. BSSO for mandibular advancement and counterclockwise
rotation
with 2–3-mm posterior open bite. Note the maxilla is moved upward (crossed black lines) on
the

48. Images showing 1-week post-surgery showing fulfilment
of objectives

49. (Top row) Images showing 1-month post-surgery images with lower anterior intrusion
carried out by bilateral intrusion arms. (Middle row) Images taken at 4-month post-surgery
showing placement of TAD in the lower left segment for lower left second molar protraction
in the extraction space

50. Images showing settling elastics

51. Post-treatment extra- and intra-oral images

52. ■ Two-jaw surgery: The mandible was advanced to edge-to-edge bite, and a
LeFort I, three-piece osteotomy was planned for the correction of maxillary
skeletal protrusion and also for the buccal crossbite correction.
■ This created an orthodontically treatable malocclusion post-surgery.

53. MANAGEMENT OF SKELETAL CLASS III
■ The treatment objectives were classified into three main categories, and they are:
1. Skeletal objectives.
■ (a) To correct the hypoplastic maxilla.
■ (b) To normalize the prognathic mandible.
2. Dental objectives.
■ (a) To upright the retroclined lower anterior teeth (in Cases 1 and 3).
■ (b) To retract proclined upper and lower anterior teeth (in Case 2).
■ (c) To correct a severely collapsed upper arch.
■ (d) To alleviate upper and lower arch crowding.
3. Soft tissue objectives.
■ (a) To restore facial harmony.
■ (b) To produce an aesthetically satisfactory face.

54. CASE 1
■ A Class III molar and canine relation, mild crowding of upper and lower
anterior teeth, dental midlines matching, and reverse overjet of 3 mm.
■ A cone beam computed tomography scan (CBCT) reveals the absence of
skeletal
asymmetry and no abnormality of the temporomandibular joint.

55. • Initial images showing pre-treatment extra- and intra-oral photos of a female with Class III
prognathic profile, Class III molar relationship, and moderate crowding in the upper and
lower arch

56. Images showing intra- and extra-oral photographs just before surgery. Note, in this
case,
all four first premolars were extracted during the bonding appointment (1 week before
the
surgery)

57. CBCT scan and 3D photogrammetry images
confirmed the clinical assessment clearly
showing mandibular prognathism and increased
lower anterior face height. Further, these images
were used for 3D surgery planning
The final 3D prediction showing improved
facial features along with establishment of
orthodontically manageable malocclusion

58. Images showing intra- and extra-oral photographs taken 1-week post-surgery. The
planned 3D surgical simulation is successfully emulated in the patient. All the objectives of SFOA
as enumerated in the text have been successfully achieved with minimal facial swelling. Anterior
box elastics, posterior bilateral Class III, and vertical configuration settling elastics were placed
immediately after the surgery in the operation theatre itself. Proper instructions were provided to
the patient for the placement of the same. Note the elastics were placed on K-hooks with ligature
wires in the upper and lower arches

59. Images taken at seventh day post-surgery; the ligature wires were replaced
with 0.016″ NiTi upper and lower arch wires

60. Nine months post-surgery, rectangular 0.017″ × 0.025″ TMA wires were placed in the
upper and lower arches. Intra- and extra-oral photographs showing Class I molar and canine
relationships along with the resolution of both skeletal and dental problems

61. Intra- and extra-oral photographs showing post-treatment images with a balanced
face
and excellent Class I molar and canine relationship

62. Initial images showing pre-treatment extra- and intra-oral photos of a female with Class
III prognathic profile, Class III molar relationship, severe crowding, and bimaxillary
proclination in the upper and lower arch
CASE 2

63. A bijaw surgery was planned using ‘3D surgery planning software’. A mandibular
setback
sagittal split osteotomy along with maxillary LeFort I advancement surgery was
planned
taking into account the 6DoF essential to resolve the skeletal problems associated
with this patient.

64. Immediate post-surgery CBCT images showing orthognathic skeletal relationship
establishment. However, the proclination of upper and lower incisors and severe crowding still
need to be resolved; therefore, first bicuspid extractions were planned

65. Images showing intra- and extra-oral photographs of patient at 8 months post-
surgery.
0.017″ × 0.25″ TMA upper and lower arch wires are placed after the resolution of
crowding. Note, the patient is ready for retraction of upper and lower anterior
teeth.

66. At 18 months post-surgery, 0.017″ × 0.025″ SS upper and lower arch wires are placed. The
proclination of upper and lower anterior teeth are corrected, along with completion of space
closure.

67. Intra- and extra-oral photographs showing post-treatment images with a balanced
face
and excellent Class I molar and canine relationship

68. Post-treatment CBCT images showing orthognathic skeletal relationship with normal
occlusion

69. CASE 3
Initial images of a very severe Class III skeletal patient with severe anterior open bite,
retroclined and crowded lower incisors

70. Upper and lower 0.014″ NiTi wires were placed in the upper and lower
arch

71. ■ Model surgery was performed to predict the surgery outcome. Based on the
cephalometric and clinical assessment, the following surgeries were planned: LeFort I
osteotomy, bilateral sagittal split of the mandible, and mandibular anterior segmental
osteotomy.
■ The maxilla was rotated clockwise to upright the excessive upper incisor inclination such
that the inclination lies within the orthodontically treatable perimeter. The lower first
premolars were extracted and anterior segmental osteotomy was performed, and the
occlusion was set up in a Class III molar relationship with a large incisor overjet during
surgery.
■ This creation of large incisor overjet would enable decrowding of severely crowded lower
anterior teeth and, also, would enable uprighting of the same.
■ Note the upper second molars are still in crossbite even after surgery planning. A
transpalatal arch will be placed to correct the crossbite post-surgery

72. Radiographs taken immediately post-surgery showing achievement of surgical objectives.
A constricted with a buccal root torque transpalatal arch was placed across bilateral upper
second molars to correct the crossbite

73. A chin cap was applied to prevent the mandibular skeletal relapse in the first 3 months
postoperatively. The retroclined lower incisors and excessive overjet were then decompensated
and
aligned postoperatively to obtain a normal inclination and overjet

74. Images showing correction of dental malocclusion within a period of 4–6 months. The
most dramatic change was noticed in the lower anterior crowding alleviation and buccal crossbite
correction of upper second molar

75. Bilateral cantilever mechanics was used in the lower arch for the uprighting and intrusion
of lower anterior teeth. 0.017″ × 0.025″ TMA wires were placed in the upper and lower arch
wires

76. Patient images showing after space closure. TPA was placed in the lower arch for
the
correction of uprighting of bilateral second molar

77. Intra- and extra-oral photographs with lateral cephalograph showing achievement of
treatment objectives

78. Management of Skeletal Asymmetry
■ The correction of maxillo-mandibular jaw asymmetry primarily depends upon
prompt diagnosis of the problem and a clear differentiation between relative
(subclinical) normal asymmetry from obvious asymmetry arising from a genetic
predisposition (congenital), acquired (injury, disease), and developmental
conditions .
■ Facial asymmetry should be determined whether it arises from dental,
skeletal,muscular, functional, or a combination of factors.

79. CASE 1
■ A 24-year-old male presented with chief complaints: large twisted lower jaw and
difficulty in chewing.
■ Extra-orally, he presented with a concave profile, asymmetrical mandible with a
left-sided chin deviation, increased lower anterior facial height, positive lip step,
asymmetrical smile line, and a shallow submental fold .
■ Intra-orally, he showed Class III molar and canine relationship with the presence
of mild anterior crowding (Fig. 10.1). Cone beam computed tomography scan
(CBCT) showed skeletal asymmetry of the mandible with a chin deviation of 7
mm to the right side

80. pre-surgical intra- and extra-oral photographs and CBCT images
showing
asymmetry

82.  The asymmetry is predominantly defined in terms of MMC roll rotation.
 To evaluate (photographic evaluation) roll relative to soft tissues (top row images),
intercommissural line is used in reference to intercanthal line. On smiling, a positive roll with the
left side is raised upward, and the right side is lowered in relation to the intercommissural line that
is evident.
 Radiographic evaluation (using CBCT images) (middle and bottom row images) showed, under
the influence of positive roll of the maxilla, the menton has deviated in the left direction.
 A negative yawing (intergonial plane) (left-side movement) indicating lower anterior yaw relative to
the direction of menton deviation.
 Furthermore, evaluation of the anterior and posterior maxillary cant showed the roll
is similar and parallel to each other in both anterior and posterior regions of the maxillary occlusion.
The same form of canting is emulated in the mandibular occlusion also.

83. Top images showing articulator mounted models exacting the clinical
and radiographic assessments.
(Bottom images) A double jaw surgery (LeFort I and bilateral sagittal
split osteotomy) was planned to correct the maxillo-mandibular
complex primarily focussing on the role and yaw rotation.
Once the maxilla’s roll rotation was corrected by impacting maxilla on the right side
(slanted black lines), subsequently, mandible yawing was corrected with asymmetrical
bilateral sagittal setback (more setback on the right side in comparison to left side) such
that upper and lower arch dental midlines were matching in the midsagittal plane (red
vertical line).
Note the achievement of Class I molar and canine relation.
Furthermore, using CBCT images, a sliding (to the right side) and advancement
genioplasty were planned to further correct the anterior yawing and recessive chin (shallow

84. One-week post-surgery extra- and intra-oral images showing fulfilment of surgery
objective

85. Pre & Post surgery patient care
Pre surgery
Systemic evaluation
Patient informed consent
Medications anesthesia clearance
Pre-operative anxiety
Social support
Orthodontic assessment

86. Post surgery
Mental cognitive assessment
Postoperative pain management
Oral prophylaxis guidance
Postoperative nutrition
Orthodontic assessment

88. COMPLICATIONS
■ PRE-SURGERY ;
1. Surgery planning is not accurate
2. Unable to establish two- or three-point contact in a transitional occlusion
3. Splint ill-fitting during try-in
4. Distorted splint
 DURING -SURGERY
1. Bracket debonding
2. Ligature wire breakage
3. Ill-fitting surgical wafer
4. Teeth not in position as planned

89. ■ POST-SURGERY
1. Occlusion instability
2. Limited mouth opening
3. Decreased chewing efficiency
4. Excessive dryness of lips
5. Open bite (a) Immediate (b) Late
6. Dental damage
(a) Teeth broken or chipped off
(b) Pulp necrosis, root resorption
(c) Decalcification
7. Periodontal complications. (a) Dehiscence (b) Gingivalrecession or fenestration

90. SFOA VS ORTHOGNATHIC
APPROACH (AJO DO 2017)
■ Patients were randomly assigned into two groups
■ Patients of both the group remained in the hospital for an average of 4days after
surgery.
■ Patients were given self-administered questionnaires before 1 month
preoperatively and 1 month postoperatively.
■ Functional limitation, physical pain, psychological discomfort,physical
disability,psychological disability,social disability and handicap.
■ On overall consideration about quality of life assessment with questionaires , we
can state that surgery-first approach has proven provide immediate
improvement over quality of life.

91. Treatment in 41 Days Using a Customized
Passive Self-Ligation System and the
“Surgery First” Approach;CASE REPORT (2019 JCO).
 A 21-year-old male requested an enhanced
chin projection to improve his occlusal relationship
and facial esthetics .
 The patient had a straight profile with excessive
lower facial height,a dental Class III
malocclusion, minor crowding in both arches,
edge-to-edge incisor relationships, and slightly
proclined upper and lower incisors.
 Radiographic analysis indicated a mild skeletal
Class III pattern and mandibular macrognathism.
 The panoramic radiograph showed adequate
root
integrity and anatomical symmetry.

92.  A 4mm maxillary advancement was planned by simulating the
osteotomies in 3D using ProPlan CMF.
 The brackets were removed after only 41 days of orthodontic
treatment, with a marked improvement in the vertical facial relationship
and
 the occlusion .
 Final photographs showed minor inflammation. Excellent stability was
observed 24 months after treatment

93. CONCLUSION
■ Performing orthognathic surgery before orthodontic treatment has multiple
advantages including but not limited to shortened treatment time, increased
patient acceptance, and the utilization of the regional acceleratory phenomenon.
■ If the cases are selected carefully, the orthodontist and the surgeon are
experienced enough to predict the final occlusion beforehand, and the level of
cooperation between the clinicians is high, the results are very promising

94. ■ Even the slightest error during the treatment planning, surgical, and post-
surgical orthodontic steps can be very difficult to correct.
■ By utilizing the principles of surgery first technique, the pre-surgical orthodontics
period can be shortened even if it is not eliminated.
■ The patient’s well-being and chief complaint should always be the first priority.

95. REFERENCES
■ Current status of the surgery-first approach (part I): concepts and orthodontic
protocols Choi et 2019.
■ Orthodontic-orthognathic interventions in orthognathic surgical cases: “Paper
surgery” and “model surgery” concepts in surgical orthodontics Contemp Clin
Dent. 2016 Jul-Sep; 7(3): 386–390.
■ SURGERY FIRST ORTHOGNATHIC APPROACH: A REVIEW ARTICLE Vol. 6
Issue 1, February 2016
■ Surgery first orthodontic management : A clinical guide to a new treatment
approach
■ Sfirst orthognathic approach vs traditional orthognathic approach : Oral health-
related quality of life assessed with 2 questionnaires 2017.