Surgery First Orthognathic Approach (SFOA)

In order to solve the serious problems of traditional surgical
orthodontic treatment, a new approach was adopted:
the first step is OGS, and this is followed by orthodontic alignment. This approach is named as Surgery First Orthognathic Approach (SFOA)

1. THE SURGERY-FIRST
ORTHOGNATHIC APPROACH
Arun Bosco Jerald
2018 Batch
Seminar on:
1

2. CONTENTS
•Introduction
•History
•Comparison ofConventional andSurgery-First
Orthognathic Approaches
•Indications
•Contraindications
•Favorable and Unfavorable Cases For SFOA
•Classification
•One Patient Two Problem Concept
•Diagnosis andTreatment Planning ofSFOA
•Biological Principles and Responses to SFOA
•Molecular Response
•Biomechanical Principles of SFOA
•Protocol in SFOA
•Management of Skeletal Class I Malocclusion
•Management of Skeletal Class II Malocclusion
•Management of Skeletal Class III Malocclusion
•Surgery first protocol with clear aligner
treatment
•Advantages
•Disadvantages
•Conclusion
•References
2

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.
•Surgical orthodontic treatment traditionally involves presurgical
orthodontic preparation, including dental alignment, incisor
decompensation, and arch coordination.
•But some disadvantages have been recognized.
3

4. •One drawback is the long presurgical treatment time that typically
worsens facial appearance and exacerbates the malocclusion.
•Thstcan increase the total treatment time with no significant
benefit for the patients. (Proffitand White)
•In some countries, these have caused patients to seek plastic
surgeons to perform orthognathic surgeries without any
consideration for occlusion.
4

5. •In order to solve those serious problems of traditional surgical
orthodontic treatment, a new approach was adopted:
the first step is OGS, and this is followed by orthodontic alignment.
•This approach is named as Surgery First Orthognathic Approach
(SFOA)
5

6. HISTORY
•Conventional jaw surgery did originate sometime in the 18
th
century
(1849) when an American oral surgeon, Simon Hullihen(considered
as the father of oral surgery), first performed jaw surgery to correct
a prognathic mandible.
•In1944,Dingmanreported cases receiving surgery before
orthodontics .
•In 1954, J.B. Caldwell and G.S. Letterman devised a vertical
osteotomy of the ascending ramus to allow for setback of the
mandible followed by direct wire fixation.
6

7. •In 1957, two Austrian oral surgeons, Richard Traunerand Hugo
Obwegeser, introduced sagittal split osteotomy, which then
marked the foundation of the modern era of jaw surgery.
•1959 -Skaggssuggested that patients with minor dentition
problems may receive surgery before orthodontic treatment.
•Obwegeserwas the first to develop LeFortosteotomy to move the
maxilla in all three dimensions in 1969.
7

8. 2018Sugawara et.al. The Application of Orthodontic Miniplates
to Sendai Surgery First
1991 Brachvogelet.al. Suggested potential
advantages of SFOA
1994 Lee Orthodontic treatment is
easier to perform post
surgically
1)Orthodontic movement does not interfere with
compensatory biological responses
2)Dental movements can be based on an already
corrected skeletal pattern, and
3)Some surgical relapse can be managed during
treatment
2003 Tsurudaet. al.Case report
2008 Sugawara et.al. Case report
8

9. 1)Orthodontic movement does not
interfere with compensatory
biological responses
2)Dental movements can be based on
an already corrected skeletal pattern,
and
3)Some surgical relapse can be
managed during treatment
9

10. 2018Sugawara et.al. The Application of Orthodontic
Miniplates to Sendai Surgery First
2011Bell and Finn (JOMFS). Surgery First approach:
a paradigm shift in
orthognathic surgery
Treatment duration is shorter by 1 to 1.5 years
Called as Surgery First Accelerated Orthognathic Approach
10
2019 Min-Suk et.al Clear Aligner Use Following
Surgery-First Mandibular
Prognathism Correction

11. COMPARISON OF CONVENTIONAL AND
SURGERY-FIRST ORTHOGNATHIC APPROACH
11

12. 12

13. 13

14. 14

15. 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/ retroclinationof 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.
15

16. CONTRAINDICATIONS
•Patient who require definite decompensation
•Severe crowding
•Arch-incoordination
•Severe vertical or transverse discrepancy
•Patients with high expectations of treatment outcomes in terms of
dental aesthetics and stable occlusions.
•Severe proclination of upper and lower anteriors.
16

17. FAVOURABLEAND UNFAVOURABLE CASES FOR SFOA
17

18. CLASSIFICATION
SFOAs can be classified into two different styles.
1. The orthodontic-driven style.
•Skeletal problems are solved by surgery, and
•Dental problems are fixed orthodontically.
•Referred to as Sendai SF (SSF).
•This approach is possible because the SAS biomechanics
provide us with the ability to predictably control the three-
dimensional movement of the bimaxillary molars.
18

19. However, some of the drawbacks of this technique are
(1)overreliance on SAS,
(2)post-surgical complex orthodontic tooth movement,
(3)added cost of SAS, and
(4)additional surgical intervention for removal of SAS post-treatment
2. The surgery-driven style.
•The aim is to solve both skeletal and dental problems by OGS as
much as possible.
19

20. 20

21. ONE PATIENT TWO PROBLEM CONCEPT
•The skeletal complexities are corrected via jaw surgery, and a
transitional occlusionis set up as the second problem,
i.e. the dental problem,
which is managed with conventional orthodontic treatment.
•The transitional occlusionis transfigured into a final occlusion to
establish a cusp-fossa relationship,
to ensure structural durability, functional efficiency, and aesthetic
harmony
21

22. DIAGNOSIS ANDTREATMENT PLANNING OF SFOA
Patient evaluation, photographs,
study models, and radiographs
22

23. BIOLOGICAL PRINCIPLES AND RESPONSES
Regional acceleratory phenomenon (RAP)
•Harold M.Frost, an American orthopaedicsurgeon, first described
RAP as ‘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 tissues that brings about healing within a period of
time.
23

24. •This ubiquitous phenomenon plays a primary role in the healing
process of all tissues.
•Further, in order to better define the remodellingprocess at the
fracture site, Frost observed the existence of numerous remodelling
sites and referred them as basic multicellular units (BMUs).
24

25. •The BMUs respond to various biomechanical stimuli and are
characterized by several distinctive phases,
(a)activation phase
(b)resorption phase,
(c)resting (or reversal) phase, and
(d)formation phase,
which represent the events involved in the bone healing process.
commonly abbreviated as ‘ARF sequence’.
25

26. 26

27. 27

28. Systemic Acceleratory Phenomenon (SAP)
•Mueller, Schilling, and team at the University of Heidelberg,
Germany, conducted a series of experiments to show that
restoration of a local defect in a rat model not only leads to RAP
but also to SAP at distant sites of the skeleton.
•SAP leads to the release of osteogenic growth peptide (OGP)
which stimulates proliferation of alkaline phosphatase activity that
ultimately accelerates bone repair process.
28

29. Role of soft tissues
•Eric Liouet.al (JOMFS, 2011)
•After mandibular set back, a Class III malocclusion becomes a
Class II.
•The resulting improvement in the tone of the upper lip and tongue
increases the force on the incisors of both arches, improving the
efficiency of incisor decompensation.
•This phenomenon may also be a factor in reducing total treatment
time.
29

30. MOLECULAR RESPONSE
•Serum alkaline phosphatase(osteoblastic activity) and C-terminal
telopeptideof Type I Collagen (osteoclastic activity) are two bone
markers which are studied for RAP.
•The results of study by Eric Liouet. al.. (2011)showed 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 2 months after surgery
30

31. •Zingleretal. (2017) evaluated biological changes using GCF
markers.
•The GCF markers, such as IL-1 b, IL-6, TGF b 1-3, MMP-2, and VEGF,
were studied before and after SFOA
•They concluded that bone remodellingfactors levels are elevated,
which is reminiscent to fracture healing
31

32. BIOMECHANICAL PRINCIPLES OF SFOA
Natural Head Position: 2D and3D
•Natural head position is the position of the head when the subject
looks at a distant point at eye level and their visual axis is parallel to
the ground.
•It forms a postural basis for assessment of craniofacial morphology
•Once the image is captured in NHP, further, NHP proof images can
be used to plan surgery in the six degrees of freedom (6DoF).
32

33. Six Degrees ofFreedom(6DoF)
•SFOA demands an in-depth understanding of dentofacial traits and
various rotational and translational movements, in order to establish
a surgical treatment objective (STO).
•6DoF refers to the freedom of movement of a rigid body in three-
dimensional space.
•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,
33

34. (1) sagittal,
(2) transverse, and
(3) vertical,
and three rotation axes
(1) pitch, (2) roll, and (3) yaw
34

35. 35

36. Pitch
•Defined as the body’s rotation fixed between the side-to-side axis
(on a patient’s right ear to left ear or left to right lip corners) also
known as the lateral or transverse axis.
•Referred as positive when the anterior segment is raised upward
and posterior segment is lowered.
36

37. Roll
•Defined as the body’s rotation fixed between the front-to-back axis
(on a patient’s lip to back of head or ANS to PNS) also known as
the longitudinal axis.
•Referred as positive when the left side is raised upward and the
right segment is lowered
37

38. Yaw
•Defined as the body’s rotation fixed around the
vertical axis (on a patient’s superior border of
calvaria to mandible base).
•Referred as positive when the anterior segment
moves to the right
38

39. •The maxillary template with maxillary plane (ANS-PNS) is one of the
key elements for planning six degrees of freedom movements.
•Although infinite movements are possible whilst correcting the
maxillo-mandibular complex (MMC), however, Chai et.al.
recommend application of some important pivotal pointsto
correct the translational and rotational movements of maxilla.
39

40. (1)distal to PNS,
(2)at PNS,
(3)in between ANS-PNS,
(4)at ANS, and
(5)mesial to ANS
•These pivotal points could be used in conjunction with correction of
translation deficiency.
•The yaw correction can be visualized in the maxillary mounted cast
and can be corrected accordingly
40

41. PROTOCOL IN SFOA
Pre-surgical
procedures
Surgical
procedure
Post-
surgical
procedure
41

42. PRE-SURGICAL ORTHODONTICS
•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
Orthodontic Appliances(Brackets andArch Ligation)
•All SFOA practitioners (both orthodontist and surgeons) have
their own individual technique and treatment philosophies that
suit them as a team.
42

43. •Bracket slot size:
▪The most commonly used bracket slot sizes are 0.018″×0.025″
(0.46×0.64mm) and 0.022″×0.028″ (0.56×0.7mm).
▪0.022″×0.028″ bracket slot allows the insertion of heavier arch
wires making the levelling and aligning easier.
43

44. TIMING OF BONDING IN SFOA
•Sugawaraand Nagasakarecommended 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

45. •Chunget. al.. 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.
45

46. 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 SS wires.
•Liouet. al. did not place any orthodontic archwires before surgery.
•Ching et. al. used 0.016x0.022” superelasticNiTi wire.
46

47. •Carlos et. al. opted to use 0.16”X0.16” NiTi wires at time of surgery.
•The use of NiTi wires translates into immediate tooth movement
after surgery which can be an advantage.
•Sugawaraand Nagasakapreferred 0.18”x0.25” SS wires and
0.19”x0.26” SS wires in 0.022 slot, adapted to all teeth for preventing
any tooth movement.
•Full slot withstands the forces resulting from intermaxillary fixation.
47

48. Images showing complex wire bending in order to
adapt to the unresolved pre-treatment tooth positions.
48

49. Surgical hooks:
•Kobayashi ligature hooks (K-hook) (0.012″ or 0.014″) ligated around
the bracket require no use of heavy arch wire,
•making not only easy to use but often becomes the only option in
cases where the inter-bracket span is markedly reduced (e.g.
severe crowding).
49

50. Image showing passive stainless steel ligature wires used to secure the
brackets before surgery (right side) and K-hooks ligated to the brackets. Post-
surgery, K-hooks are utilized to hook elastics
50

51. •Several authors have termed the planned occlusion that is
determined during model surgery as the transitional occlusion,
treatable malocclusion, surgical temporary occlusion, or intended
transitional malocclusion(ITM).
•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.
DETERMINATION OF TRANSITIONAL OCCLUSION
51

52. •The ‘transitional occlusion’ could be transfigured into a final
occlusion to establish a stable relationship between the occlusion
and corrected skeletal structures.
•There is an ideal anatomic relationship with opposing dentition
exhibiting a cusp to fossa relationship which results in structural
durability, functional efficiency, and aesthetic harmony.
52

53. 53

54. Prerequisites ofaTransitional Occlusion
•In the conventional orthognathic surgery approach, pre-surgical
orthodontic treatment is performed such that the dental
component is decompensated to reveal the true skeletal
discrepancy.
•The pre-surgical orthodontics ensures fabrication of a ‘surgical
splint’ such that the maxilla and mandible are placed in a
‘concrete occlusion’ with minimal post-surgical orthodontic
treatment.
54

55. •In SFOA, as teeth are malpositionedand lack proper occlusal
antagonists in opposite arch, a ‘transitional occlusion’ has to be set
up post-surgically.
55

56. Some key elements are as follows:
•Sagittal plane –
•For minimal or moderate crowding cases, establishing positive
overjet or an occlusion with three-point contact with two points
contacting at the posterior teeth preferably at bilateral molars
and one point at the anterior teeth such that a tripod effect is
created.
•The three-point contact with one point contacting the anterior
teeth should be attempted only if the inclination of the anterior
teeth is within normal limits.
56

57. •If the anteriorsrequire correction (retroclinedor proclined), then it’s
prudent to avoid using the anterior teeth for a three-point contact
and should resort to a two-point contact of bilateral posterior teeth.
•For severely retroclinedor crowded lower anterior teeth and
proclinedupper anterior teeth cases, creation of larger positive
overjet such that the large overjet can be utilized for lower incisors
uprightingor decrowdingand/or retraction of proclinedupper
incisors.
57

58. •A two-point contact of bilateral posterior teeth should be
attempted in the aforementioned scenario, as referencing the
anterior teeth will not be appropriate.
•Liao et. al.. recommended considering extraction if the upper
incisor to occlusion plane angulation is less than 53–55°
58

59. •Transverse plane
•Intercanineand intermolar width of upper and lower dentition is
maintained.
•Crossbite not more than one buccal cusp width of maxillary
molar.
59

60. •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.
60

61. Merits
•Transitional occlusion model set-up permits evaluation of
possibilities of SFOA
•Pre-surgical dental decompensation is avoided
•Possible to ascertain post-surgical arch wire sequencing
61

62. Demerits
•Both the surgeon and orthodontist require experience to visualize
the postsurgical transitional occlusion
•Requires accurate prediction of the postoperative orthodontic
treatment for dental alignment, incisor decompensation, arch
coordination, and occlusal settling
•The surgeon must be proficient at performing planned osteotomies
with surgical splint on dental arches with existing malocclusion and
achieve required postsurgical stability
62

63. PAPER SURGERY AND MODEL SURGERY
•Offers a simple and reliable method of assessing and formulating
the treatment plan of a dentofacial deformity using routinely
available tools of assessment such as photographs, study models,
and radiographs (cephalographs).
•The diagnostic information obtained from clinical findings and
radiographic assessments are integrated in the paper surgery to
establish a surgical plan.
63

64. •The paper surgery is emulated on a face-bow transfer, articulator-
mounted study models in model surgery for surgical splint creation.
•The treatment plan, when using 2D data, is essentially a composite
of clinical evaluation and cephalometric (both Lat. & PA ceph)
assessment using Schwarz’s Gnathic profile field (GPF).
•Also, rule of thirds is applied for the evaluation and correction of
face.
64

65. 65

66. 66

67. •Three horizontal planes and one vertical plane are drawn on the
PA cephalographand two horizontal reference planes on the
lateral cephalograph.
•PA cephalography:
•Horizontal planes
•topmost plane (cranial reference plane) runs between the
intersection of superior border of greater wing of sphenoid bone
and lateral orbital margin, right and left.
67

68. •The middle plane (orbital plane) runs from midpoint of inferior
orbital margin, right and left.
•The bottom plane (maxillary canine plane) runs from maxillary
canine—tip of maxillary canine, right and left.
•The vertical plane:
•Midsagittal plane (a plane dropped from crista galli)
68

69. •In SFOA planning, the maxillary canine
plane is subjective and may not be
reliable as the teeth are not aligned,
hence making maxillary canine plane
difficult to use
69

70. •Lateral cephalograph:
•Horizontal planes
•Frankfort horizontal plane,
•Runs from the midpoint of the upper contour of the external
auditory canal (anatomic porion) or a point midway
between the top of the image of the left and right ear rods
of the cephalostat(machine porion) to a point midway
between the lowest point on the inferior margin of the two
orbits (orbitale).
70

71. •Maxillary plane
•Runs from ANS to PNS
•The maxillary template with maxillary plane
(ANS-PNS) is one of the key elements for
planning six degrees of freedom
movements.
71

72. 72

73. •The amount of rotation and translation movements would be
confirmed during the model surgery, and the surgical splints are
created.
•The maxilla was moved according to the paper surgery planning
and fixed to create the intermediate splint by keeping mandible in
its original position.
•Once the intermediate splint was created, the mandible was
moved as planned.
•Subsequently, the final surgical splint is created.
73

74. •The aforementioned conventional jaw surgery approach poses
several drawbacks at various levels, and they are
(1)2D representation of a complex 3D maxillofacial structure,
(2)incorporation of cephalometric tracing errors during planning,
(3)face-bow transfer and dental model mounting errors, and
(4)model surgery errors, surgical splint fabrication-induced errors,
etc.
•If these are controlled, ‘paper and model surgery’ is beneficial as it
allows the clinician to utilize the routine tools of assessment without
depending on supplementary modalities.
74

75. 3D VIRTUAL SURGICAL PLANNING AND 3D SPLINT FABRICATION
•3D imaging modalities such as CBCT helps to visualize intricate
details of the craniofacial structures accurately and enables the
cranial base superimposition with a voxel-wise method.
•This has made it possible to analysestructures such as TMJ and the
extent to which craniofacial structures respond post-surgically.
•Very complex dentofacial deformities especially the asymmetric
cases can be planned using computer-assisted surgical simulation
and splints can be virtually fabricated
75

76. 76

77. SPLINTS IN SFOA
•The primary purpose of the surgical splints is to emulate the planned
surgical movement.
•Once the osteotomy cuts are made and the jaws are placed in the
planned position, the final surgical splint is usually discontinued.
•Literature indicates the use of final surgical splint as a post-surgical
occlusal guidewith the intention that it will minimize the occlusal
instability during bone healing. (1-4 weeks )
•If so, it requires frequent selective grinding to accommodate tooth
movement.
77

78. •Nagasakaet. al. have used removable
Gelb–type splintspost operatively.
•They preferred to use it for about 4 -6
weeks aftersurgery
•Sugawara et. al. modified the surgical
splint into a removable maxillary occlusal
splint
78

79. •The surgical splint as a post-surgical occlusal guide may not be
necessary because:
1.Rigid fixations can overcome the instability that might follow.
2.Occlusal guide grinding demands precision and considerable
chairside time.
3.Minimal mouth opening, during the postoperative recovery time,
the patient will be under remarkable stress during the surgical
splint maneuvering.
79

80. Intermaxillary Fixation
•IMF serves as a mode of immobilizing the jaw segments
•Different techniques :
direct interdental wiring,
IMF screws,
arch bars,
eyelet wiring, and
cap splints
80

81. The objectives of minimizing the duration of the IMF and surgical splint :
•Commence OTM as soon as possible such that RAP can be utilized to
the maximum.
•The rigid internal fixation, if done adequately, is sturdy enough to
resist relapse which is thought to occur due to premature occlusal
interferences.
•If the IMF is left for several weeks post-surgery, one must consider
additional days of hospitalization along with postoperative recovery
issues such as assisted feeding and oral hygiene deterioration.
81

82. TREATMENT CONSIDERATIONS IN
SKELETAL CLASS I IN SFOA
•Skeletal Class I patients requiring surgery predominantly exhibit a
severe sagittal discrepancy, either in a bimaxillary protrusion or a
retrusion relationship.
•Could be corrected either by en-bloc distalization or mesialization
of the MMC by performing LeFortI osteotomy and bilateral sagittal
split osteotomyor by anterior segmental osteotomy.
•In such cases, Control of maxillary occlusal plane is the key for the
successful treatment.
82

83. 0
83

84. •The factors to be considered when performing these surgeries
would be
(1)the extent of surgical movement required for the correction of the
complexity and
(2)the amount of extraction space utilization especially created
during anterior segmental osteotomy surgery.
84

85. •Segmental osteotomy is primarily indicated when the discrepancy
is defined by the following conditions:
1.Dental proclination requiring extraction space for the correction
of anterior teeth inclination.
2.Moderate to severe crowding requiring extraction space for
unravelling of crowding.
85

86. TREATMENT CONSIDERATIONS IN
SKELETAL CLASS II IN SFOA
•Skeletal class II malocclusion typically involves proclinationof
mandibular incisors and upright/mild proclinationof 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
86

87. •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.
•The resulting improvement in the tone of the lower lip and tongue
increases the forces acting on the incisors in both arches.
87

88. •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 uprightingthe upper
anteriors, 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.
88

89. 89

90. 90

91. TREATMENT CONSIDERATIONS IN
SKELETAL CLASS III IN SFOA
•In these cases, the lower incisors are usually crowded and
retroclinedwhile the maxillary incisors are 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
•It requires class II orthodontic mechanics after surgery and
adjustment of the anterior teeth can be managed postoperatively.
91

92. 92

93. 93

94. 94

95. POSTOPERATIVE PROCEDURE IN SFOA
•The objectives of orthodontic treatment after surgery in the SFOA
technique are dental alignment, arch coordination, and occlusal
settling, that together might take another6-12 months.
•Leelasinjaroenet. al. suggested postsurgical orthodontic treatment
could begin as early as 1 week -1 month postoperatively.
•Kim et. al. suggested to wait 4-6 weeks.
•The surgical splint and IMF should be removed for the tooth
movement
95

96. POST-SURGICAL ORTHOPAEDICMANAGEMENT,
I.E. CHIN CUP THERAPY
•Post-surgery use of chin cup appliance in Class III patients provides
a substantial support for the retention of Class III correction, thus
ensuring minimal or no skeletal relapse.
•It is important to apply the chin cup as early as possible, preferably,
within a week post-surgery whilst taking care of facial swelling that
has occurred after surgery.
•The chin cup should be continued for the first 3–4months post-
surgery. Appropriate cushioning has to be provided for patient
comfort.
96

97. •Wear duration:
Apply as soon as possible postoperatively with full-time
application in the first month followed by nighttime (10–12h) wear
in the second and third months.
•Force magnitude:
begin with lighter force of approximately 250g (9Oz) per side
and gradually increase to 450g (16Oz ).
97

98. •The chin cup can be
•occipital-pull, intended for patients that had shown mandibular
protrusion with horizontal growth pattern, and
•a vertical-pull, which could be used for vertical growth pattern
with excessive anterior facial height
98

99. SURGERY FIRST PROTOCOL WITH CLEAR ALIGNER TREATMENT
•Case selection for Surgery First patients may be assessed by setting
up the surgical jump at stage 1 and evaluating for 3 point occlusal
contacts in the occlusion
•In the Clinchecksoftware, set up the tooth movements to remove
existing dental compensations and position the teeth over the
basal bone.
•This can be assessed by evaluating the pre-surgical occlusion when
the surgical jump is set up for the end of treatment
99

100. •Then plan the orthognathic surgery using 3D CBCT and virtual
surgical treatment planning
•Compare the immediate post-surgical model or 3D CBCT with the
existing Clincheckplan
•Modify the plan to approximate the immediate post-surgical
occlusion at stage 1
•Then only approve manufacture of aligners
100

101. •The aligners are inserted 3 weeks post-surgery and patients are
currently changing the aligners every 5 days to take advantage of
RAP in the immediate post-surgical period.
•Some authors suggest two sets of aligner per stage: the soft and
hard types, per week
101

102. ADVANTAGES OF SFOA 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
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103. DISADVANTAGESOF SFOA
•Planning may be time consuming as it needs to be very accurate
to prevent any errors
•Predicting final occlusion is difficult
•Ideal occlusion may be hard to achieve if there are multiple dental
interferences
•Patient selection is of utmost importance
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104. CONCLUSION
•Performing orthognathic surgery before orthodontic treatment has
multiple advantages including: shortened treatment time,
increased patient acceptance, and the utilization of RAP.
•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
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105. •Even the slightest error during the treatment planning, surgical, and
postsurgical 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.
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106. 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 ContempClin 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,
ChaiKiatChng, NarayanH.Gandedkar, EricJ. W.Liou
•Sfirstorthognathic approach vs traditional orthognathic approach : Oral healthrelatedquality
of life assessed with 2 questionnaires 2017
•Sugawara et.al, The Application of Orthodontic Miniplates to Sendai Surgery FirstThe
Application of Orthodontic Miniplates to Sendai Surgery First, Seminars in Orthodontics,2018.
•Min-Suk et.al, Clear Aligner Use Following Surgery-First Mandibular Prognathism Correction. The
Journal of Craniofacial Surgery Volume 30, Number 6, September 2019
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