40th Publication -JMOS- 5th Name.pdf orthognathic article

40th Publication -JMOS- 5th Name.pdf

1. 123 Journal of Maxillofacial and Oral
Surgery

ISSN 0972-8279

J. Maxillofac. Oral Surg.
DOI 10.1007/s12663-019-01269-y
Current Orthognathic Practice in India: Do
We Need to Change?
Philip Mathew, Paul C. Mathai, Jisha
David, Usha Shenoy & Rahul Tiwari

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3. INVITED REVIEW ARTICLE
Current Orthognathic Practice in India: Do We Need to Change?
Philip Mathew
1
•Paul C. Mathai
1
•Jisha David
1
•Usha Shenoy
2
•Rahul Tiwari
1
The Association of Oral and Maxillofacial Surgeons of India 2019
AbstractThe last decade or so has seen paradigm shifts in
the various aspects of orthognathic surgery. A lot of these
changes are to do with digitalization of the orthodontic-
surgical workflow, optimization of surgery-first protocols,
virtual surgical planning-based 3D printing solutions and
changing patient-health-care dynamics. The aim of this
article is to provide evidence-based recommendations that
are both practical and economically viable for the current
orthognathic practice in India.
KeywordsTrendsOrthognathic surgeryEvolution
IndiaChange
Introduction
Orthognathic surgery is probably the most beloved domain
of all maxillofacial surgeons as it requires a combination of
advanced surgical skills and an in-depth understanding of
the stomatognathic system. I have been actively performing
orthognathic surgery over the majority of my surgical
career and felt honored when approached by the Journal of
Maxillofacial and Oral Surgery to write a review paper on
the same. This paper has given me the chance to pen down
my thoughts regarding the changing trends of orthognathic
surgery over the past two decades in India. I also hope to
give my opinion regarding how this branch will embrace
the future in our country.
The Demand for Orthognathic Surgery
The need to look better is becoming more and more
prevalent in today’s society. Good looks have always been
associated with a better career, a higher social status and
better self-esteem. Thus, it is no surprise that cosmetic
surgery has been a billion dollar industry in the west for
quite some time [1]. However, the same was not the case
when I began my surgical practice at Jubilee Mission
Medical College (Thrissur, Kerala) 24 years ago. The idea
of undergoing surgery to improve facial cosmesis was
unappealing to majority of the patients unless the facial
deformity was severe or functionally debilitating. Fur-
thermore, the need to perform a procedure under general
anesthesia was generally perceived as risky and reserved
only when surgical intervention was absolutely essential
(e.g., trauma, head and neck cancers, ischemic heart
disease).
Over the last decade or so, there has been a reversal of
the above perception in India and other countries (e.g.,
Middle East, Latin America). Easy and affordable access to
the Internet through smart phones and the presence of
social media are mainly responsible for this change. Social
media platforms (e.g., You Tube, Facebook, Snapchat,
&Philip Mathew
[email protected]
Paul C. Mathai
[email protected]
Jisha David
[email protected]
Usha Shenoy
[email protected]
Rahul Tiwari
[email protected]
1
Department of Maxillofacial Surgery, Jubilee Mission
Medical College, Thrissur, India
2
Department of Anesthesiology, Jubilee Mission Medical
College, Thrissur, India
123
J. Maxillofac. Oral Surg.
https://doi.org/10.1007/s12663-019-01269-yAuthor's personal copy

4. Twitter and Instagram) have made it easy to compare one’s
physical appearance to others in their own peer groups or to
their role models (e.g., sportspersons, film stars). As a
result, the current generation of young adults is more
exposed to appearance-related feedback as compared to the
previous generation. This increases the risk of being
marked out as different, bullied or teased, which can end up
as the chief reason for seeking out cosmetic surgery [2].
Certain image centric media platforms (e.g., Snapchat and
Instagram) allow digital filters to be applied to mobile
camera photographs (e.g., selfies) which morph the
patient’s face toward a more pleasing esthetic profile. Thus,
the patient is subconsciously exposed to the potential to
look better, which becomes an additional reason to seek out
cosmetic surgery.
Today, various surgical procedures are explained on
information dispensing websites (e.g., youtube.com, wiki-
pedia.org, webmd.com, mayoclinic.org, medscape.com)
via easy to understand text and animated videos. Patients
also go out of the way to document the entire surgical
process on social media platforms through written reviews
and videos. The depth of documentation can be extensive
extending from the first consultation and preoperative
preparation to the immediate postoperative phase and long-
term results (e.g.,www.realself.com). Many of my current
patients have decided to undergo treatment after accessing
the information on these digital platforms and going
through the reviews of patients who have already under-
gone the procedure.
Patients are more willing for surgery as the risks asso-
ciated with general anesthesia are far lower today than
what they were two decades ago. The media (e.g., inter-
views with film stars who have undergone cosmetic sur-
gery, medical-based television series) is also responsible
for lessening the stigma associated with undergoing a
procedure under general anesthesia. These perceptions
have made patients more willing to undergo a surgical
cosmetic procedure.
The cost of facial cosmetic surgery has also decreased,
and patients today have increasing economic power and
consider investing in an improved cosmetic appearance as
a valuable life-changing investment. All the above factors
have led to an increasing demand for orthognathic surgery
in the current Indian scenario.
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) consists of a preoccu-
pation with a perceived defect. The ‘‘defect(s)’’ is not
noticeable to other people (or is minimal); however, it is
associated with shame, depression and a poor quality of
life. A review of the literature reveals that the prevalence of
BDD in orthognathic surgery ranges between 10 and 12%.
There is a higher prevalence of BDD in developed coun-
tries (e.g., USA). This could be linked to the greater pen-
etration of social media platforms along with an increasing
appearance-related feedback that that their citizens face in
daily life. With the increasing presence of social media in
our country, we can also expect patients with BDD to
present themselves in our surgical practice [3–5].
It is important to note that patients with BDD will use
cosmetic surgery as a means to fix their perceived defect.
However, they are frequently dissatisfied with the results of
their procedure. Such patients will seek out other doctors for
treatment or may become aggressive and seek legal action.
Thus, it is important to advise a psychiatry referral if you feel
that the patient is exaggerating a nonexistent facial deformity
with evidence of clinically significant distress or impairment
in daily life on account of the same [3–5].
Treatment Sequence: Surgery Intermediate
Approach (SIA) or Surgery-First Approach
(SFA)?
The conventional approach or the ‘‘surgery intermediate’’
approach involves a period of pre-surgical orthodontics
followed by surgery and finally a period of postoperative
orthodontics. The overall duration of treatment can be
expected to range from 18 to 36 months based on the
complexity of the dento-facial deformity. During the phase
of pre-surgical orthodontics, facial esthetics and occlusion
worsen which can be extremely demotivating to the
patient.
On the other hand, a ‘‘surgery-first’’ approach allows early
improvement of the facial profile by eliminating the preop-
erative orthodontic phase and directly re-positioning the
affected jaw(s) using conventional osteotomies. It requires
the surgeon and the orthodontist to work closely and have an
in-depth understanding of both orthognathic principles and
limits of orthodontic movements. The surgeon should be
experienced enough to perform orthognathic surgery on
uncoordinated and malaligned dental arches. Greater atten-
tion is needed in the postoperative orthodontic phase if
occlusal contacts are insufficient. The poor proprioception
from such occlusal contacts can cause the patient to position
the mandible in an incorrect manner. This might influence
the long-term outcomes of the surgery [6–8].
The phenomenon of regional accelerated orthodontic
tooth movement reduces the duration of postoperative
orthodontics by allowing rapid tooth movements. This
period of increased bone metabolism lasts for 3–4 months
postoperatively. Hence, it is advisable to start orthodontic
treatment as soon as possible after surgery. The patient
needs to be recalled frequently as rapid movement of the
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5. teeth necessitates frequent adjustment of the fixed
orthodontic appliance and surgical splint [6–8].
Due to the elimination of the preoperative orthodontic
phase and the advantage provided by the regional accel-
eratory phenomenon (RAP), the overall treatment time can
be shortened significantly. Jeong et al. [9] established that
cases with SFA required an average of 14 months for
completion, while those performed with conventional SIA
required an average of 22 months. Thus, when compared to
conventional SIA, the immediate improvement of the facial
profile with the prospect of an overall short duration of
treatment greatly improves the patient’s psychological
status and cooperation in the long term [10].
The routine indication for a SFA is a skeletal class 3
case with a relatively flat curve of Spee, minimal crowding,
fairly well-aligned arches, near normal inter-incisal angles
and mild transverse discrepancy [8]. However, Liao et al.
[11] successfully used the SFA for asymmetric class 3
cases with acceptable results and high patient satisfaction.
Similarly, Kochar et al. [12] also reported a using the SFA
approach for a skeletal class 2 case with good esthetic
result and functional occlusion with an overall treatment
duration of just 7 months. Soon, well-defined SFA proto-
cols catering to a spectrum of dento-facial deformities will
become common place.
There is considerable controversy regarding the long-
term stability of the SFA approach. This can be attributed
to the fact that the body of literature comparing the two
approaches is still insufficient [13,14]. Lee et al. [15],
Jeong et al. [16], Jeong et al. [17], Baek et al. [18] and Park
et al. [19] established that some degree of postoperative
relapse (more in the vertical than horizontal dimension)
should be expected in patients who underwent single-jaw
sagittal split osteotomy setback surgery for skeletal class 3
malocclusion. This can be primarily attributed to the
rotational relapse that takes place over time while the
occlusion settles [17]. One also tends to perform larger
skeletal movements so as to make space available for
future dental decompensation. Thus, the treatment plan has
to be further refined and modernized using computerized
planning to incorporate the expected postoperative skeletal
shifts into the surgical plan.
Currently, a brief phase pre-surgical orthodontics (not
more than 3 months) has been suggested. The aim is to
grossly correct any transverse discrepancy and create at
least 3 stable occlusal stops once the jaws have been re-
positioned to provide a stable translational occlusion. This
phase of minimal pre-surgical orthodontic treatment helps
reduce postoperative instability and does not significantly
increase the duration of treatment [20].
In the conventional SIA, the orthodontist would be the
primary caregiver and the surgeon played a short but vital
role. The SIA provided a predictable occlusion and skeletal
position postoperatively, and hence, the surgeon’s role in
the postoperative phase was minimal unless a postoperative
surgical complication presented. However, the role of the
surgeon and orthodontist has changed when adopting the
SFA. The surgeon has become the primary caregiver
instead, which brings along additional responsibilities as
the patient will frequently address both surgical and non-
surgical concerns toward the surgeon. Both the surgeon and
the orthodontist need to closely monitor the patient due to
the rapidly changing occlusion and subsequent skeletal
shifts that take place in the postoperative phase [21].
In the conventional SIA, pre-surgical orthodontics
helped resolve transverse discrepancies to a great extent.
This meant that uncomplicated osteotomies could be used
for the final surgical correction. The lack of pre-surgical
orthodontic treatment in the SFA can increase the need to
perform segmental osteotomies, which increases the risk of
surgical complications. The immediate postoperative
occlusion undergoes rapid changes due to the RAP, inad-
vertently increasing the risk of temporomandibular disor-
ders. Thus, one may have to change the informed consent
to better suit the SFA so as to avoid any legal implications
in the wake of postoperative complications [21].
During the initial part of my surgical career, I lost many
patients to the prolonged treatment duration involved in the
conventional SIA. Over time, I too have adopted the SFA
approach and have benefitted greatly from it. I also rou-
tinely implement a short course of pre-surgical orthodon-
tics as mentioned above to improve the predictability of my
results.
There a few other advantages of the SFA that are less
spoken about. The shorter duration of treatment has an
economic advantage as the cost of the overall procedure is
reduced. The patient needs to restrict traveling for a period
of 12–14 months only, as compared to the conventional
SIA wherein treatment could extend up to 24–36 months.
This is important as majority of the patients that we treat
are late adolescents or young adults. They are usually
planning to pursue higher education or are employed in
jobs that require them to travel frequently or stay away
from home. Thus, a shorter overall duration of treatment
does not hamper the active lifestyle of the patient
excessively.
In the future, we are heading toward customizing the
treatment plan based on a spectrum of patient motivation
and dento-facial deformity severity as given by Hernandez
et al. [22]. For optimization of treatment, cases can be
classified on a spectrum ranging from surgery only, surgery
first, surgery early, surgery late, surgery last to surgery
never.
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6. Fast-Track/Ambulatory Orthognathic Surgery:
Can We Move Orthognathic Surgery
to the Outpatient Setting?
One should always keep in mind that orthognathic surgery
is an elective cosmetic procedure and is generally not
covered by insurance. This automatically makes it difficult
for the young patient to afford. If one were to break down
the hospital bill, general anesthesia and operating room
facilities account for a large portion of the overall cost
when operating in the hospital setting. This trend has only
increased over the last two decades. On the other hand,
basic room and medication charges remain affordable.
The west has long since adapted to this problem by
slowly moving orthognathic and other cosmetic surgery
into the outpatient setting which has helped to significantly
reduce costs. This has primarily become possible due to the
development of ambulatory general anesthesia protocols:
hypotensive anesthesia, rapid emergence and enhanced
recovery. Hypotensive anesthesia helps shorten surgery
time and reduce blood loss while rapid emergence and
enhanced recovery protocols allow for accelerated and
predictable recovery with fewer unpleasant side effects,
e.g., postoperative pain, nausea and vomiting [23–28].
There are certain limitations to the scope of surgical
procedures that can be performed in the outpatient setting.
Young healthy patients with an ASA grade of 1 or 2
(American Society of Anesthesiology) are preferred can-
didates [25,29]. There is an increased risk of postoperative
complications and delayed recovery when surgery duration
is prolonged. Ideally, the total duration of surgery should
not exceed 2 h when operating in the outpatient setting.
Thus, single-jaw surgery or uncomplicated double jaw
surgery in healthy young adults can be considered as the
preferred patient demographic [30,31].
The overall complications experienced with outpatient
orthognathic surgery are low and comparable to that per-
formed in the hospital setting [32]. In the rare case that a
complication develops or the patient experiences signifi-
cant distress, the patient can be admitted for an overnight
stay in a hospital [23,26,30]. The more common hurdle
lies in conditioning the guardian regarding the postopera-
tive recovery process. One may have to re-admit the patient
or have a private nurse accompany the patient home just
because the guardian is emotionally distressed and unable
to care for the patient. Thus, it is necessary to develop a
negotiated protocol with nearby hospitals to facilitate this
type of transfer should the situation arise. It is important to
note that this period of brief hospitalization does not sig-
nificantly increase the overall cost.
As surprising as it may seem, outpatient orthognathic
surgery has become common place in the west as early as
the 2000s [32]. In India, day care surgery centers are
slowly on the rise. It is time that we also consider moving
uncomplicated orthognathic surgical procedures to the
outpatient setting without compromising on treatment and
with all the necessary checks in place.
I firmly believe that the amount of surgical expertise
needed to safely perform orthognathic surgery in the out-
patient setting is far higher than that required in a hospital
setting. One also needs to provide a higher level of surgical
care to reduce operative time without compromising on
results, e.g., the use of virtual surgical planning, pre-bent
plates and advanced instrumentation (e.g., oscillating
saws).
Virtual Versus Conventional Surgical Planning:
Accuracy Versus Affordability?
Conventional surgical planning involves cephalometric
analysis with prediction tracing, clinical facial analysis,
face-bow registration with mounting of dental casts on a
semi-adjustable articulator, model surgery and fabrication
of splint(s) for the desired occlusion. Many of these steps
are time-consuming and technique-sensitive [33]. Today,
computer-aided virtual surgical planning (VSP) allows us
to perform 3D cephalometric analysis of the hard and soft
tissues, plan and simulate the desired surgical movements
and transfer the virtual plan to the surgical setting using a
surgical splint. Some of the commonly used programs
today are NemoFab by Nemotec, Dolphin 3D Surgery by
Dolphin Imaging and Management Solutions, Mimics by
Materialise, Individual Patient Solutions by KLS Martin
and VSP Orthognathics by 3D systems.
Various studies have proven the accuracy of the com-
puter-aided virtual planning, especially when planning
complex facial asymmetry cases [33–35]. When comparing
planned versus actual clinical outcomes, a nonsignificant
difference of less than 2 mm was present when using VSP
[36–38]. Some studies have reported a fall in accuracy of
the soft tissue profile in the lower lip and chin region. Thus,
care must be taken to prevent the patient from developing
unrealistic expectations when using a software-generated
facial profile as a visual aid [39].
Unlike the west, computer-aided planning has just
started to integrate itself into mainstream surgery in India.
There are three major reasons for the same: cheaper 3D
printing solutions, cloud computing and native home-based
3D solutions. A decade or so before, 3D printing was still
very expensive. Today, this technology has become wide-
spread and affordable. One can buy an entry-level 3D
printer with the required printing materials for a measly
20,000 INR on a website likewww.amazon.in.
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7. With the advent of cloud computing, one can simply
upload the DICOM data (CT or CBCT scan), scanned
dental models and clinical photographs of the patient to the
desired cloud-based program to create the data set needed
for subsequent planning. The graphic user interface for
current programs are very simple and can be easily
understood by a clinician. Real-time technical help is
available throughout the process. Once the case has been
planned, the surgical guides are printed and transported to
you. The cost of planning is charged per case. If you are
consulting a company abroad, you can export the STL file
of the splints and have them printed locally at a lower cost.
One no longer needs to invest in buying the whole soft-
ware, dedicated hardware and training personnel to operate
it. The only investment needed is that of a high-speed
Internet connection.
In my opinion, the most important reason for rapid
acceptance of VSP is the presence of India-based compa-
nies dealing with 3D solutions. They have created a
financial model that is affordable and fits into the India
health-care system. They provide free training to surgeons
and institutions to help familiarize them with the process of
virtual surgical planning. The cost of 3D planning a routine
bi-jaw orthognathic case along with the fabrication of two
3D printed splints does not exceed 14,000 INR (Rs. 2500
for CBCT scan, Rs. 1500 for dental model scans and Rs.
5000 per splint).
The cost of overall surgery has to be re-assessed when
incorporating VSP into your practice. It has always been
said that ‘‘Time saved is money earned.’’ When compared
to conventional planning, VSP improves accuracy while
significantly reducing the difficulty and time required for
planning. Maximum benefits are seen when planning bi-
jaw and complex facial asymmetry cases [33–35,40–42].
As mentioned previously, cost for using general anesthesia
and operation theater facilities make up a large part of the
hospital bill [30]. As the duration of surgery increases, one
can expect delayed recovery and increased risk of post-
operative complications which ultimately prolong the
duration of hospital stay. Evidence today has made it clear
that VSP can reduce the duration of surgery, thus allowing
for faster recovery and early discharge. Furthermore, the
costs associated with admission to an intensive care unit for
management of postoperative complications due to pro-
longed anesthesia can also be avoided [43]. Thus, a small
investment in VSP can help reduce the overall cost of
surgery while helping the patient recover earlier.
It has been said that ‘‘VSP allows an average surgeon,
on an average day, to deliver a good surgical result’’ [44].
One can no longer claim that virtual surgical planning is
beyond the scope of the Indian health scenario. It is nec-
essary to integrate this technology into our daily practice
and take the efforts to get trained for the same. Only then
will we be able to prove to a potential patient that they are
in safe hands and that we can deliver on the results that we
have promised.
A lot of my patients are already aware of VSP and are
impressed when we offer them the option. They do not
mind the additional cost as it promises accuracy. Further-
more, the surgical plan can be shared with the patient as a
visual aid to better understand the procedure.
Condylar Positioning, Splints, Instrumentation
and Fixation Techniques: Where are We Headed?
Splints: Conventional Versus 3D Printed and 3D
Surgical Guides Versus Navigation Surgery
Conventional splints need frequent modification (e.g.,
grinding or addition of material). They demonstrate poor fit
due to the polymerization shrinkage that occurs when using
self-cured acrylic resin. Impressions of poor quality and
wearing of the occlusal surfaces (due to frequent manipu-
lation of the casts) can similarly affect the fit of the splint.
Errors during model surgery (e.g., incorrect face-bow
registration, mounting and bite registration) lead to failure
to capture the correct centric position, inadvertently
affecting the accuracy of the splint [38,43–45].
When performing virtual surgical planning, the centric
position can be easily captured and laboratory errors can be
avoided. Furthermore, 3D printing is an additive process
which helps negate the effects of polymerization shrinkage.
The above advantages increase the accuracy and fit of a
VSP 3D printed splint [38,43–45]. It is my opinion that we
should start using VSP 3D printed splints as the benefits
outweigh the disadvantages, at least for bi-jaw or complex
facial asymmetry cases.
3D surgical guides are VSP 3D printed splints with
extra-oral bone borne support. These guides have posi-
tioning arms which make it possible to position the oper-
ated jaw(s) in the desired position using the skull base as
reference. Evidence has demonstrated that they are as
accurate as conventional VSP 3D printed splints in routine
cases with greater accuracy in complex facial asymmetry
cases [46–48].
The use of 3D surgical guides is not without disadvan-
tages. The duration and difficulty of the surgery may
increase as additional operation site exposure is required
for better adaptation of the guide. If the anterior wall of the
maxilla is thin, screw fixation might fail and desired
adaptation of the guide would not be possible. The bulky
nature of the guide can pose an interference during the
fixation process. Lastly and most importantly, they increase
the cost of surgery significantly. In my opinion, there are
only few situations that warrant the use of such splints:
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8. firstly, a junior surgeon attempting to correct a complex
facial asymmetry case and secondly, anyone attempting re-
operative orthognathic surgery in a complex facial asym-
metry case.
The next paradigm shift would be the incorporation of
navigation surgery (NS) into routine orthognathic surgery.
NS allows us a real-time comparison of the new position of
the jaw(s) to the proposed virtual surgical plan. Studies
have established that accuracy of NS is catching up to that
of VSP 3D printed splints and guides [46,47]. One must
remember that in certain scenarios (e.g., correction of open
bite, facial asymmetry and skeletal cant), the surgical splint
has a vital and indispensable function, i.e., to stabilize the
maxilla and mandible during plate fixation. Unless a work
around can be established, navigation surgery will only
remain an adjunctive tool in the hands of the orthognathic
surgeon. Furthermore, the systems being used today are
bulky and difficult to use, leading to a significant increase
in operating time.
In the future, we can surely expect a commercial NS
device adapted to orthognathic surgery. However, to what
degree it can add value to the overall surgery is unknown.
One also needs to consider the steep learning curve and
lack of training opportunities when using this technology.
The financial burden of such a device can be reduced if
shared between multiple departments, e.g., otolaryngology
and neurosurgery. It is my opinion that the use of NS may
be warranted only in complex facial asymmetry cases
wherein one has to be doubly sure of the surgical result so
as to avoid unnecessary re-operative surgery [49].
Condylar Positioning: Do We Need to Move
on from Manual Seating?
The need to seat the condyle in the correct position in the
fossa during orthognathic surgery is of utmost importance.
Failure to do so leads to postoperative condylar sag which
can affect the occlusion significantly. Manual seating of the
condyle continues to be the most commonly used method
today with acceptable results [50]. The use of ultrasound,
condylar positioning devices (CPD) and modified general
anesthesia protocols during orthognathic surgery have
never moved beyond the role of adjunctive tools [51–53].
Reviews by Costa et al. [54] and Ellis [55] could not
conclude whether CPDs provided any added benefit during
surgery.
With the advent of VSP and NS, has there been any
improvement in intra-operative seating of the condyle?
Wan et al. [56] concluded that VSP 3D printed splints did
not reduce the changes to condylar position and angulation
that resulted from conventionally planned orthognathic
surgery. Bettega et al. [57], Bettega and Leitner [58],
Bettega et al. [59] and Nova et al. [60] have documented
acceptable results using experimental NS protocols to re-
position the condyle. However, larger multi-centric studies
are needed to truly confirm the benefits of using this
technology as compared to manual seating of the condyle.
In my opinion, manual seating of the condyle will
continue to remain the most commonly used method.
However, one may require considerable time before per-
fecting the technique as it is essentially a blind procedure.
Using adjunctive tools (like ultrasound, CPD and modified
general anesthesia protocols) is strictly a personal choice.
Instrumentation and Fixation Techniques: Can We
Do Better and is It Worth It?
Today, the two commonly used rigid fixation techniques
are bi-cortical positional screws and miniplates. Numerous
studies have established stable and consistent results with
both systems [61]. So, why change? The question of
adaptation does not arise when using a bi-cortical posi-
tional screw. However, adaption of the miniplate to the
osteotomy site requires a considerable skill. If one lacks
experience, repeated attempts are required. Nonetheless,
the skill is easily learned over time and does not increase
intra-operative time significantly.
In my opinion, plating the maxilla is far easier due to the
ease of access and adequate surface area. Plating the
mandible is always more difficult on account of lesser
surface area, difficult access and need for manual seating of
the condyle. The operator is always tempted to forcefully
adapt the overlapping bony shelves during a sagittal split
osteotomy. This can have a deleterious effect on the
condylar position, especially when performing large set-
backs in severe prognathic mandibles and asymmetric
movements for mandibular asymmetry cases.
Though a senior surgeon can tackle these difficulties,
can the same be said for a junior surgeon? One can choose
to manually pre-bend the miniplates on a stereolithographic
model with the jaw(s) in the final position and the condyle
seated correctly using VSP. This helps to avoid unneces-
sary torquing of the condyle and save time during the
fixation phase. The cost of a single-jaw stereolithographic
model is in the range of Rs. 2000 to Rs. 4000. The cost can
be further reduced by printing out the region of interest
only. The cost of the model seems insignificant when you
can avoid a postoperative complication that can ruin the
entire surgical-orthodontic effort, especially when treating
severely prognathic or asymmetric mandibles.
The next big wave is the patient specific implant (PSI).
The PSI perfectly incorporates the desired jaw movement
and also adapts beautifully to the underlying bone. Studies
have already established that these implants are time-sav-
ing and accurate with greater benefit in the maxilla than in
the mandible. However, the increase in accuracy does not
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9. justify the tremendous cost involved. There is also a risk
that the implant does not fit, which would be a huge loss of
investment [46,47,62–64]. I believe that PSIs are the
future, but only if cost of production decreases. Only time
will tell.
Changes in the Intra-operative Routine to Improve
Postoperative Recovery
As surgeons, we always aim to minimize duration of
exposure to general anesthesia, perform the surgery quickly
and efficiently and keep complications to a minimum. This
is no doubt a difficult task. Changes in our intra-operative
routine to achieve the above goals are most welcome.
A single preoperative dose of 8 mg dexamethasone
helps reduce post-surgical airway and maxillofacial edema
with minimal side effects. It also has a synergistic anal-
gesic effect when combined with postoperative analgesics.
Preoperative and intra-operative tranexamic acid can help
reduce blood loss significantly which can promote early
recovery [65–67]. With respect to infection control,
orthognathic surgery is considered to be of the clean-con-
taminated type. A single preoperative dose of 1.2 g
amoxicillin–clavulanic acid is sufficient to bring down the
rate of infection considerably. One can choose to extend
the antibiotic prophylaxis for up to 24 h after the surgery.
However, long-term prophylaxis does not contribute sig-
nificantly to reducing surgical site infection. One must
remember that consuming large amounts of antibiotics in
the postoperative phase only adds to the discomfort of the
patient without offering any real benefit [68,69].
Hypotensive anesthesia is a boon to the orthognathic
surgeon as it provides a clean hemostatic field, reduces
blood loss and shortens hospital stay. There is an associa-
tion between hypotensive anesthesia and optic nerve
damage. Risk of optic nerve damage due to retinal artery
occlusion increases in head and neck surgery when the
mean arterial pressure falls below 60 mmHg, surgery is
prolonged ([6 h), and a large amount of blood loss
([1 L) has taken place. This risk may further increase if a
pterygo-maxillary dysjunction is performed as stray forces
can dissipate toward the optic foramen with a magnitude
potent enough to cause damage to the optic nerve and
retinal artery. Thus, I prefer to maintain hypotensive
anesthesia throughout the surgery except during pterygo-
maxillary dysjunction [27,28,70]. One also has the option
to reduce the forces required for pterygo-maxillary
dysjunction by using a piezoelectric surgical device to
weaken the junction [71].
Investing in advanced instrumentation and VSP 3D
printed splints for routine cases can reduce the time needed
for surgery without increasing risk [43]. As an added
measure of safety, 3D surgical guides can be considered for
complex facial asymmetry cases. An oscillating saw pro-
vides immense benefits over rotary instrumentation with
respect to speed and fineness of the cut. There have been
attempts to perform the complete osteotomy with a piezo-
surgical device. Various advantages have been cited, e.g.,
reduction in blood loss, swelling and nerve impairment
[72,73]. However, it is my personal experience that this
would significantly increase intra-operative time. Instead, I
would suggest that the initial osteotomies be made with the
oscillating saw. The cuts can be further deepened with a
piezo-surgical device to allow for a more predictable frac-
ture and simultaneously reduce risk of nerve damage.
A lesser known advantage of VSP is the ability to plan
and modify the sagittal split osteotomy (SSO) cut so as to
avoid nerve damage. This is important as there is a high
incidence of inferior alveolar nerve (IAN) damage during
routine SSO and the subsequent numbness significantly
affects the quality of life [74,75]. I find that this feature
might be particularly useful when treating mandibular
prognathism wherein the nerve courses closer to the buccal
cortex of the mandible [76].
The use of osteotomes/chisels alone for completing the
sagittal split has been associated with a higher incidence of
IAN paresthesia. This can be attributed to the larger
amount of force applied and sharpness of instrument.
Alternatively, the combined usage of splitters and separa-
tors through gradual spreading and prying movements
reduces the risk of nerve damage. In my opinion, one
should use the chisel/osteotome only when unable to
complete the split with splitters and separators. As men-
tioned previously, one can also consider using a piezo-
surgical device to complete the sagittal split osteotomy
cuts. Thus, lesser force would be needed for performing the
actual split which reduces the risk of nerve injury as well.
The risk of bad splits while performing the SSO can be
reduced by rounding off the sharp angles of the SSO cuts
and extracting the mandibular third molar at least 6 months
earlier. In my opinion, one of the main reasons for a bad
split is the lack of completion of the SSO cuts. When in
doubt, it is advisable to insert the separator into the
osteotomy site and re-define the cuts with an osteotome/
chisel/piezo-surgical device under direct vision.
All of us have experienced those instances wherein the
desired soft tissue profile was not achieved in spite of the
underlying skeletal change. At times, the stretching of the
tissue envelope results in a reduction in the shape and
volume of the soft tissue. One should definitely consider fat
grafting for masking such contour irregularities. Additional
benefits like reduction of postoperative edema and soften-
ing of preexisting scars have also been documented. Fur-
thermore, the harvesting technique is uncomplicated with
minimal donor-site morbidity [77].
J. Maxillofac. Oral Surg.
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10. Lastly, I wish to draw everyone’s attention to the
duration of hospital stay. When I started my practice, I
would admit patients for up to 7 days and continue intra-
venous antibiotics for the same duration. Today, I am able
to discharge most patients 1 day after surgery by imple-
menting many of the suggestions made above, similar to
hospitalization trends in the west [78].
Adding Value to Orthognathic Surgery: How Do
You Go About It?
Clinicians in the country are slowly waking up to the long-
term effects of obstructive sleep apnoea (OSA). The gold
standard for treatment of mild-to-moderate OSA is CPAP.
In cases of severe OSA or non-compliance to CPAP,
maxillo-mandibular advancement has been proved to pro-
vide significant long-term relief [79].
If the patient presents with chronic nasal obstruction and
dento-facial deformity, we should combine orthognathic
surgery with the necessary septoplasty and inferior turbi-
nate reduction. Doing so does not increase the duration of
hospital stay or the risk of complications [80,81].
In cases of complex congenital deformities (e.g., grade 3
hemifacial microsomia, TMJ ankylosis) and comminution
or resection of ramal-condylar unit (due to pathology or
severe facial trauma), one can combine orthognathic sur-
gery with custom alloplastic TMJ replacement to provide
optimal results [82].
Orthognathic surgery should no longer just be marketed
as a facial cosmetic procedure. It is our duty to rise up to
the occasion and market these additional avenues of
treatment. Efforts should be made to present the increasing
scope of orthognathic surgery at local continuing medical
education events. Those who are attached to medical col-
leges should make it a point to showcase the scope of
maxillofacial surgery to undergraduates, postgraduates and
teaching staff at every opportunity. This will go a long way
in helping our medical colleagues understand the role of
the maxillofacial surgeon.
We enjoy the benefits of digitalization daily, e.g., online
news, online restaurant reviews, online exercise tracking.
Yet we hesitate to extend the same benefits to our potential
patients. It is a request to all orthognathic surgeons to start
uploading video patient testimonials on to social media
platforms (with necessary consent). Important things to
cover would be the duration of overall treatment, difficul-
ties faced, care provided by the team, improvement in
quality of life and recommendation to others who have
similar problems. This extra effort will go a long way in
increasing patient awareness and acceptance of the
procedure.
Follow-Up and Documentation: Why Do It?
The need for documentation is far more important today
than it was before. Patients who undergo cosmetic surgery
can harbor unrealistic expectations. Hence, the cosmetic
patient community can be particularly litigious when
unhappy with the surgical result.
Detailed photographic documentation and follow-up
regarding psychological status and clinical status (e.g.,
pain, TMJ status, trigeminal nerve paresthesia, occlusion)
can help comprehensively understand the patient’s condi-
tion. These data are also very helpful if any medico-legal
issues crop up in the future. One is also able to evaluate
results in the long term and identify additional areas for
improvement in planning and surgical technique.
In my opinion, one needs to maintain follow-up and
documentation for at least 1 year after surgery preferably
up to 3 years after surgery. It is also advisable to hire
additional help as these activities can be quiet tedious and
time-consuming [83].
Summary
The effect of orthognathic surgery goes beyond simple
correction of the dento-facial deformity. The final result is
not only assessed by the surgeon and the patient, but also
by anyone that interacts with the patient. There is greater
societal acceptance of the individual which improves the
quality of life and reduces psychological stress. Thus, it is
no doubt that an orthognathic surgeon derives great
pleasure from his or her work. This does not change the
fact that we are currently living in an age of digitaliza-
tion, customization and convenience. As surgeons who
improve cosmesis through an elective surgical procedure,
it is our duty to go the extra mile and generate online
presence regarding our field and our skills. Customization
of the treatment plan using VSP is the need of the hour.
Similarly, it is imperative to adopt surgical protocols that
enhance patient convenience, e.g., shorter treatment
duration, faster recovery and greater postoperative com-
fort. I believe that greater success awaits the Indian
orthognathic surgery community if we can embrace the
suggestions above.
AcknowledgementsI would like to acknowledge Professor Dr.
Varghese Mani and Professor Dr. H.S. Adenwala for mentoring me
throughout my surgical career. I would like to acknowledge two
India-based Virtual Surgical Planning Companies for providing us
with information regarding surgical planning:http://ctars3d.in/and
https://www.osteo3d.com/.
FundingNone.
J. Maxillofac. Oral Surg.
123Author's personal copy

11. Compliance with Ethical Standards
Conflict of interestNone.
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