YIJOM-3526; No of Pages 6

Technical Note

Orthognathic Surgery

Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxxhttp://dx.doi.org/10.1016/j.ijom.2016.09.026, available online at http://www.sciencedirect.com

Inferior subapical osteotomy fordentoalveolar decompensationof class III malocclusion in‘surgery-first’ and ‘surgery-early’ orthognathic treatmentF. Hernandez-Alfaro, M.J. Nieto, V. Ruiz-Magaz, A. Valls-Ontanon, I. Mendez-Manjon, R. Guijarro-Martınez: Inferior subapical osteotomy for dentoalveolardecompensation of class III malocclusion in ‘surgery-first’ and ‘surgery-early’orthognathic treatment. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016International Association of Oral and Maxillofacial Surgeons. Published by ElsevierLtd. All rights reserved.

Abstract. Increasing experience with alternative timing protocols in orthognathicsurgery has given way to new surgical and orthodontic techniques to shortentreatment times, reduce biological costs, and improve the final outcome. Aprospective evaluation of class III patients who received an inferior segmentalosteotomy (ISO) for decompensation of significantly retroclined lower incisors inthe context of ‘surgery-first’ (SF) or ‘surgery-early’ (SE) timing protocols wasperformed. Treatment was planned virtually. A thorough periodontal assessmentwas performed at baseline and periodically until debonding. A minimally invasivesurgical technique including selective interdental corticotomies and elective boneaugmentation was used. Patient and orthodontist satisfaction with the treatment wasevaluated. Eight patients (mean age 26.3 years) underwent surgery. One hadisolated maxillary surgery and seven had bimaxillary surgery in combination or notwith additional cosmetic procedures. The periodontal status of all patients remainedstable throughout the observation period. The mean duration of orthodontictreatment was 8.7 months in the SF group and 10.5 months in the SE group.Satisfaction with treatment was extremely high. The ISO is a safe, reliabletechnique for dentoalveolar decompensation in timing protocols with a short or noorthodontic preparatory phase. This methodology may represent a reasonableapproach in selected class III patients.

Please cite this article in press as: Hernandez-Alfaro F, et al. Inferior subapical osteotomy for

malocclusion in ‘surgery-first’ and ‘surgery-early’ orthognathic treatment, Int J Oral M

10.1016/j.ijom.2016.09.026

0901-5027/000001+06 # 2016 International Association of Oral and Maxillofacial Surge

F. Hernandez-Alfaro1,2, M. J. Nieto1,V. Ruiz-Magaz1,3,A.Valls-Ontanon1,2,I.Mendez-Manjon1,2,R.Guijarro-Martınez1,2

1Institute of Maxillofacial Surgery, TeknonMedical Centre, Barcelona, Spain;2Department of Oral and MaxillofacialSurgery, International University of Catalonia,Sant Cugat del Valles, Barcelona, Spain;3Department of Periodontics, InternationalUniversity of Catalonia, Sant Cugat del Valles,Barcelona, Spain

Key words: orthognathic surgery; segmenta-tion; subapical osteotomy; segmental osteot-omy; mandible; dentofacial deformity; surgery-first.

Accepted for publication 30 September 2016

dentoalveolar decompensation of class III

axillofac Surg (2016), http://dx.doi.org/

ons. Published by Elsevier Ltd. All rights reserved.

2 Hernandez-Alfaro et al.

YIJOM-3526; No of Pages 6

Fig. 1. Virtual simulation of the orthognathicosteotomies (frontal view).

While the correction of a dysfunctionalocclusion used to be the main therapeuticgoal for orthognathic surgery patients, thewish to improve facial aesthetics or cor-rect sleep-disordered breathing has be-come the motivation for treatment inmany cases. Moreover, supported by theperception of surgery as safe and predict-able, the number of adult patients whobecome engaged in orthodontic or com-bined orthodontic–surgical therapy is in-creasing steadily. Often, these patientspresent periodontal problems and job-timelimitations for conventional preoperativeorthodontic schemes and are good candi-dates for alternative timing approachessuch as ‘surgery-first’ (SF) or ‘surgery-early’ (SE).1–3

Besides immediate correction of thepatient’s aesthetic concern and/or compro-mised airway, the main advantage of thesetiming schemes, in which surgery is per-formed before any orthodontic treatment(SF) or after a short preparatory phase(SE), is that subsequent orthodontic treat-ment and hence the total treatment timeare significantly shorter.1–5 Improved or-thodontic efficiency is probably relatedto the increased metabolic turnover ofthe regional acceleratory phenomenon(RAP)2,5,6 and a more favourable soft tis-sue tone after skeletal base correction.3–5

Clinical experience has shown that rou-tine preoperative dental alignment, fullarch coordination, and incisor decompen-sation often tend to prolong the treatmenttime, with little or no clinically significantbenefit for the patient.4 Besides, dentalcompensation can be resolved – totallyor partially – with surgical osteotomies.This may be particularly relevant in peri-odontally compromised patients or caseswith a narrow anterior alveolar ridge,where conventional incisor decompensa-tion may lead to gingival recession or bonedehiscence and fenestration.

The so-called ‘subapical osteotomy’,‘front-block’, or ‘anterior segmentalosteotomy’ was described by Cohn-Stockin 1921.7 Almost a century of clinicalexperience later, the effectiveness of thisosteotomy, and its subsequent technicalmodifications, for the treatment of monoand bimaxillary protrusion is widely ac-knowledged.

Details of the treatment concept andexperience in SF and other alternativetiming protocols of the present studyauthors is available in the scientific liter-ature.1–3 Progressive understanding of thepossibilities and limitations of these pro-tocols has led to the development of newsurgical and orthodontic techniques tofurther shorten treatment times, refine

Please cite this article in press as: Hernandez-

malocclusion in ‘surgery-first’ and ‘surger

10.1016/j.ijom.2016.09.026

selection criteria, reduce biological costs,and ultimately improve the final outcome.In this context, the aim of the present studywas to illustrate the value of the inferiorsubapical osteotomy – with proclination ofthe osteotomized segment – for accelerat-ed decompensation of class III malocclu-sion. To this effect, a prospectiveevaluation of cases in which an inferiorsubapical osteotomy was indicated to sur-gically decompensate the antero-inferiorregion was performed. The focus was seton the analysis of selection criteria, feasi-bility of the procedure, complications, andfinal outcome.

Materials and methods

A prospective evaluation of all patientswho received an inferior subapical osteot-omy for dentoalveolar decompensationduring a 5-year time period (June 2010to June 2015) was performed. The guide-lines of the Declaration of Helsinki onmedical protocol and ethics were followedat all treatment stages. The performance ofthis study did not in any way alter thesystematized protocol used at the studycentre for the diagnosis, treatment, andfollow-up of orthognathic surgerypatients. Hence, additional approval fromthe local committee on ethical medicalpractice was not required.

Patients were selected for an inferiorsubapical osteotomy (isolated or com-bined with another facial osteotomy) onthe basis of the following inclusion crite-ria: (1) non-growing status; (2) dentofacialdeformity with significant retroclinationof the lower incisors; (3) SF or SE timingprotocol; (4) sufficient interdental space atthe selected segmentation sites to guaran-tee a periodontally safe osteotomy; (5)stable periodontal situation; and (6) in-formed consent.

In all cases, the routine protocol fordiagnostic work-up and three-dimensional(3D) surgical planning of the study centrewas followed. This method has been vali-dated and described in detail elsewhere.8

In brief, it consists of the following steps:(1) detailed interview and thorough clini-cal assessment of the patient by the com-bined surgical–orthodontic team. (2)Radiological evaluation with cone-beamcomputed tomography (CBCT) (i-CATversion 17–19; Imaging Sciences Interna-tional, Hatfield, PA, USA). (3) Dental archanatomy registration by digital scanning(Lava Scan ST Scanner; 3M ESPE, AnnArbor, MI, USA). (4) Generation of anaugmented virtual skull model with accu-rate representation of the bony and dentaltissues by .stl file fusion (CBCT plus

Alfaro F, et al. Inferior subapical osteotomy for

y-early’ orthognathic treatment, Int J Oral M

intraoral scan). (5) 3D virtual orthodonticsetup, in which the orthodontist predictsthe final (at the end of orthodontic treat-ment) position and axial inclination ofeach individual tooth. This is a crucialstep prior to the surgeon’s skeletal basecorrection simulation in complex SF andSE cases, where the patient’s baselineocclusion cannot serve as a reliable guidefor skeletal repositioning. (6) Virtual sim-ulation of the orthognathic osteotomies,including the inferior subapical osteot-omy, with Dolphin Imaging (version11.0; Chatsworth, CA, USA) (Figs 1 and2). The ideal interdental site for segmen-tation (between the lateral incisor andcanine, or between the canine and firstpremolar) is chosen based on arch shapecorrection objectives and the amount ofinterdental space for a safe osteotomy. Theamount of proclination given to the front-block segment in the software is corrobo-rated on the dental casts. (7) CAD/CAM(computer-aided design and computer-aided manufacturing) production of theintermediate and final splints.

The preoperative periodontal evaluationconsisted of a complete periodontal chart-ing. The following parameters wererecorded at baseline: plaque index, prob-ing pocket depth (PPD), gingival reces-sion, bleeding on probing, and clinicalattachment level (CAL). All measure-ments were taken by the same calibratedexaminer. PPD was measured from thegingival margin with a CP-11 periodontalprobe. Gingival recession was measuredfrom the cemento-enamel junction to thegingival margin (gingival recession wasequal to 0 whenever the cemento-enameljunction was covered). CAL was calculat-ed by adding the values of gingival

dentoalveolar decompensation of class III

axillofac Surg (2016), http://dx.doi.org/

Inferior subapical osteotomy for decompensation 3

YIJOM-3526; No of Pages 6

Fig. 2. Virtual simulation of the orthognathicosteotomies (profile view).

Fig. 3. Inferior subapical osteotomy and interdental corticotomies to facilitate orthodonticdecrowding.

recession and PPD. All measurementswere made at six sites per tooth: mesio-vestibular (mv), central-vestibular (cv),distovestibular (dv), mesiolingual (ml),central-lingual (cl), and distolingual (dl).Two weeks prior to treatment, all patientswere scheduled for oral hygiene instruc-tions as well as for professional supragin-gival debridement according to individualneeds, and the patient’s ability to maintainoptimal oral hygiene standards waschecked.

In cases managed with SF, no preoper-ative orthodontic preparation apart frombracket bonding 2–7 days before surgerywas implemented. In this group ofpatients, the first soft archwire was notplaced until 24 h before surgery in order toavoid dental movements that could renderthe CAD/CAM splint inaccurate.

All patients were operated on undergeneral anesthesia by the same surgeon(FHA). Monomaxillary cases (mandibularbilateral sagittal split osteotomy and orinferior subapical osteotomy) were treatedin an outpatient context. Bimaxillary caseswere discharged after 24 h.

The surgical approach for the inferiorsubapical osteotomy consisted of a hori-zontal incision between the two lateralincisors at a level below the attached gin-giva and above the buccal sulcus. Themucoperiosteal flap was elevated carefullyto expose the prospective box-shapedosteotomy line. A piezoelectric microsaw(Implant Center 2; Satelec-Acteon Group,Tuttlingen, Germany) was used to designthe osteotomy and to perform additionalinterdental corticotomies at selected sites,

Please cite this article in press as: Hernandez-

malocclusion in ‘surgery-first’ and ‘surger

10.1016/j.ijom.2016.09.026

with the aim of further enhancing the RAPand facilitating orthodontic decrowding.While corticotomies were interruptedwhen the superficial spongiosa wasreached, and hence light bleeding wasdetected, the boundaries of the inferiorsubapical osteotomy were deepened to-wards the lingual cortex (Fig. 3). At thevertical interdental segmentation sites, theattached gingiva of the papilla was onlyslightly elevated and the piezoelectricabutment was tunnelled upwards towards,but not reaching, the inter-alveolar crest.The osteotomy was completed with gentlerotation manoeuvres of a 6-mm straightosteotome (Epker DO-181; Bontempi, Tut-tlingen, Germany). Once repositioned, norigid fixation system, besides the adaptedarchwire itself, was used to fix the segmentin its final position. Additionally, interden-tal gaps greater than 3 mm were grafted(Apatos, OsteoBiol; Tecnoss, Giaveno,Italy). Likewise, horizontal osteotomygaps greater than 3 mm were grafted inorder to smooth the transition betweenthe chin and the repositioned front-blocksegment.

Postoperative orthodontic treatmentwas started no later than 2 weeks postop-eratively in order to benefit from the RAP.At this point, the composite bridges wereremoved and the archwire was substitutedwith expanding coils. If necessary, theinclination of the intermediate mandibularfragment was further modified with elasticmechanics.

Postoperative CBCT imaging was per-formed 1 month and 1 year after surgery.Periodontal checkups were scheduled on amonthly basis during the first two postop-erative months and then every 3 months.A final check-up was performed afterorthodontic debonding. The following

Alfaro F, et al. Inferior subapical osteotomy for

y-early’ orthognathic treatment, Int J Oral M

parameters were evaluated: plaque index,PPD, gingival recession, bleeding on prob-ing, and CAL.

Patient satisfaction with treatment wasevaluated on a 0–10 visual analogue scale(VAS) at the 6-month follow-up appoint-ment.

Results

During the 5-year study period, a total ofeight patients (three female, five male)underwent an inferior subapical osteotomyfor dentoalveolar decompensation pur-poses at the study centre (Table 1). Theirmean age at the time of surgery was 26.3years (range 14–49 years). For all patients,the preoperative malocclusion was skeletalclass III with combined sagittal-transversemaxillary hypoplasia and severely com-pensated mandibular incisors.

The inferior subapical osteotomy wasperformed between lateral incisors andcanines. In seven cases, interdentalcorticotomies were executed within thefront-block segment and in any additionallocation indicated by the orthodontist. Onepatient underwent isolated maxillary sur-gery and seven patients underwent bimax-illary surgery (one-piece or segmented LeFort I osteotomy plus mandibular bilateralsagittal split) in combination or not withadditional cosmetic procedures. Sixpatients were operated on according tothe SF protocol. A SE approach was fol-lowed in the remaining two.

Postoperative recovery was uneventfulin all patients. Bimaxillary cases weredischarged 24 h after surgery, and theso-called ‘monomaxillary’ case (Le FortI plus inferior subapical osteotomy) wasoperated on in the morning and dischargedin the late afternoon.

dentoalveolar decompensation of class III

axillofac Surg (2016), http://dx.doi.org/

4 Hernandez-Alfaro et al.

YIJOM-3526; No of Pages 6

Table 1. Demographic characteristics, surgical procedure, timing protocol, total treatment time, and satisfaction with treatment for the studysample.

Case Sex

Age at timeof surgery,

years Orthognathic surgery procedureAncillary cosmetic

procedure(s)Timingprotocol

Total treatmenttime, months

Satisfaction withtreatment (VAS)

Patient Orthodontist

1 F 17 Bimaxillary surgery:Four-piece LFI + BSSOInferior subapical osteotomy

Rhinoplasty SF 8 10 10

2 M 38 Bimaxillary surgery:One-piece LFI + BSSOInferior subapical osteotomy

GenioplastyMalar augmentation(PBFP technique)Cervical liposuction

SF 10 10 10

3 F 14 Bimaxillary surgery:One-piece LFI + BSSOInferior subapical osteotomy

Recontouring of themandibular lower border

SE 12 10 10

4 F 27 Bimaxillary surgery:Four-piece LFI + BSSOInferior subapical osteotomy

GenioplastyMalar augmentation(PBFP technique)

SF 12 10 9

5 M 25 Bimaxillary surgery:Four-piece LFI + BSSOInferior subapical osteotomy

– SF 8 8 9

6 M 49 Bimaxillary surgery:Four-piece LFI + BSSOInferior subapical osteotomy

– SF 7 10 9

7 M 18 Bimaxillary surgery:One-piece LFI + BSSOInferior subapical osteotomy

Genioplasty SF 7 9 9

8 M 23 Monomaxillary surgery:One-piece LFIInferior subapical osteotomy

– SE 9 9 10

BSSO, bilateral sagittal split osteotomy; F, female; LFI, Le Fort I osteotomy; M, male; PBFP, pedicled buccal fat pad; SE, surgery early; SF,surgery first; VAS, visual analogue scale.

The mean duration of orthodontic treat-ment was 8.7 months (range 7–12 months)in the SF group and 10.5 months (range 9–12 months) in the SE group. Patients ratedtheir satisfaction with treatment as ex-tremely high (average 9.5, range 8–10).

The periodontal status of all patientsremained stable during the observationperiod. No significant increases in PPDor gingival recession were observed. Withindividualized preoperative hygieneinstructions, plaque index levels remainedunder 20% during the whole study. Onepatient (patient 6 in the series) suffered a6-mm gingival recession with necrosis ofthe lateral incisor adjacent to the segmen-tation site. He admitted heavy smokingthroughout the postoperative period.

Changes in PPD and gingival recessionwere considered as CAL changes. Themean PPD value was 3.2 � 0.9 mm atbaseline and 3.5 � 1.0 mm at debonding.The mean gingival recession value was0.6 � 1.2 mm at baseline and 0.7 �1.3 mm at debonding. The mean CALvalue was 3.8 � 1.4 mm at baseline and4.2 � 1.2 mm at debonding. The plaqueindex showed a stable percentagethroughout the study: the mean value atbaseline was 17% and at debonding was19%.

Please cite this article in press as: Hernandez-

malocclusion in ‘surgery-first’ and ‘surger

10.1016/j.ijom.2016.09.026

Figure 4 shows a complete case; thevirtual planning shown in Figs 1 and 2is for the same patient.

Discussion

Orthodontic proclination of the mandibu-lar incisors has traditionally been consid-ered a risk factor for gingival recession,root resorption, and bone fenestration anddehiscence.9,10 This issue may be of criti-cal importance in patients with an initiallyinadequate buccolingual width of kerati-nized gingiva (0–2 mm),9,11,12 a narrowmandibular symphysis where the teethmay be moved out of their osseous enve-lope,10,12,13 or gingival inflammation andinadequate plaque control.11–13

Class III patients tend to have signifi-cant dental compensations with sagittalretroclination of the anterior mandibularteeth. In addition, radiological examina-tions reveal a narrow symphysis and min-imal labiolingual bone coverage of theincisor roots in many cases. It is a commontrend that more adult patients – often withdifferent degrees of periodontal disease –are becoming engaged in orthognathicsurgery treatments.3 In this context, con-ventional orthodontic preparation with fullaxial correction of the mandibular incisors

Alfaro F, et al. Inferior subapical osteotomy for

y-early’ orthognathic treatment, Int J Oral M

and reopening of the compensated anteriorcrossbite can be biologically dangerousand technically time-consuming. More-over, the gradual accentuation of thepatient’s prognathic profile becomes amajor aesthetic concern.2,3

An alternative to orthodontic decom-pensation is surgical decompensation withan inferior subapical osteotomy. Althoughthis osteotomy was originally designed tocorrect alveolar protrusion by retroposi-tioning the osteotomized segment,7 ante-ropositioning the latter can result in partialor total resolution of the dental compen-sation. In the authors’ experience, the totaltreatment time and extent of orthodonticmovements – hence the biological risks –are significantly reduced, not only becauseof axial dentoalveolar relocation, but alsodue to improved orthodontic efficiency.This facilitated tooth movement is proba-bly a consequence of a more favourablesoft tissue tone after skeletal base correc-tion3–5 and transient demineralization ofthe operated bone due to the RAP.2,5,6 TheRAP can be further enhanced with theexecution of additional interdental corti-cotomies within the osteotomized front-block segment.

Most current virtual planningsoftware packages enable the design

dentoalveolar decompensation of class III

axillofac Surg (2016), http://dx.doi.org/

Inferior subapical osteotomy for decompensation 5

YIJOM-3526; No of Pages 6

Fig. 4. Case 3 (see Table 1 for surgical details). Preoperative extraoral (A and B) and intraoral (C) pictures. Intraoperative view of the inferiorsubapical osteotomy (D). Final extraoral (E and F) and intraoral (G) pictures after debonding.

and incorporation of the inferior subapi-cal osteotomy in the treatment plan. Inthe authors’ practice, most bimaxillarycases are managed with a mandible-firstprotocol. This means that the inferiorsubapical osteotomy is incorporated inthe intermediate splint, which is alwaysmanufactured through CAD/CAM. Al-ternatively, the amount of proclinationgiven to the front-block segment canbe omitted from the intermediate splintand incorporated in the final splint.

Compared to other facial osteotomies,the inferior subapical osteotomy is techni-cally simple, the rate of potential compli-cations is low, and the long-term stabilityis adequate.14 As with other segmentalosteotomies of the jaws, damage to theperiodontal hard and soft tissues is mini-mal and is not a reason to avoid theseprocedures.15 The key issue is adequateselection of the sites for interdental seg-mentation. The decision should be basedon arch shape correction objectives andthe amount of interdental space. The lattershould be sufficient to allow a safe osteot-omy that does not compromise the vitality

Please cite this article in press as: Hernandez-

malocclusion in ‘surgery-first’ and ‘surger

10.1016/j.ijom.2016.09.026

of the adjacent teeth. In cases managed bySF approach, this can be an importantlimiting factor. It is required that the adja-cent roots are, if not divergent, at leastparallel. Otherwise, a short preparatoryorthodontic phase – hence, a SE protocol– is recommended. At any rate, compre-hensive 3D evaluation of the local anato-my with CBCT and the use of apiezoelectric microsaw should be consid-ered systematically in order to minimizethe periodontal risks. Despite these pre-cautions, one patient in the present seriesexhibited gingival recession and necrosisof one lateral incisor. He admitted toheavy smoking throughout the entire post-operative period. No other complicationsarose.

It has been suggested that segmentalalveolar osteotomies may entail difficul-ties in maintaining an adequate bloodsupply to the osteotomized segment.16

In the authors’ opinion, this potential riskis irrelevant in inferior subapical osteo-tomies if performed through a minimallyinvasive buccal approach, because theblood supply is maintained integrally

Alfaro F, et al. Inferior subapical osteotomy for

y-early’ orthognathic treatment, Int J Oral M

through the intact periosteal and muscleattachments on the lingual aspect andbasal border. Moreover, the buccal muco-periosteal flap is elevated only to exposethe prospective box-shaped osteotomyline, such that the blood supply fromthe buccal sulcus is also minimally dis-rupted.

Although the patients included in thisstudy were all class III cases managed bySF or SE approaches, the indications forinferior subapical osteotomy may be ex-tended to other types of malocclusion andalternative timing schemes. Regarding thefirst aspect, the inferior subapical osteot-omy may be indicated for any kind ofmalocclusion where substantial move-ment of the mandibular frontal teeth isrequired but where isolated orthodontictooth repositioning is risky or impossibledue to objective factors such as the amountof tooth movement required or periodontalcircumstances, or subjective factors suchas patient age, treatment time, and eco-nomic status. In particular, although classIII malocclusions are more common in theauthors’ clinical practice, skeletal class II

dentoalveolar decompensation of class III

axillofac Surg (2016), http://dx.doi.org/

6 Hernandez-Alfaro et al.

YIJOM-3526; No of Pages 6

deformities with significant dental com-pensations due to orthodontic camouflagemay also be a good indication for surgicaldecompensation with an inferior subapi-cal osteotomy, in this case by anteropo-sitioning the frontal segment. Regardingalternative timing schemes, inappropriateaxial inclination of the mandibular inci-sors may be present in a selected group ofpatients in whom orthognathic surgery isperformed with no concomitant orthodon-tic treatment or after a whole orthodontictreatment in the past for camouflage pur-poses. These are the so-called ‘surgery-only’ and ‘surgery-last’ categories, re-spectively.1

In conclusion, the inferior subapicalosteotomy is a safe, reliable techniquefor dentoalveolar decompensation in tim-ing protocols in which preoperative or-thodontic treatment is suppressed (SF) orshortened (SE). It minimizes the compli-cations of conventional orthodontic de-compensation of excessively retroclinedincisors, decreases the total treatmenttime markedly, and achieves high levelsof patient and orthodontist satisfaction.This methodology may represent a rea-sonable approach to solve significant den-tal compensation in selected class IIIpatients.

Funding

None.

Competing interests

None.

Ethical approval

The study did not alter the systematizedand already ethically approved protocolfor the diagnosis and treatment of dento-facial deformity at the study centre, andhence was exempt from specific ethicalapproval.

Please cite this article in press as: Hernandez-

malocclusion in ‘surgery-first’ and ‘surger

10.1016/j.ijom.2016.09.026

Patient consent

Patient consent is obtained systematicallyat the clinic to publish clinical photographs.

Acknowledgements. The authors wouldlike to thank Dr Orion Luiz Haas Jr forhis invaluable support with the informa-tion technology and image processing.

References

1. Hernandez-Alfaro F, Guijarro-Martınez R.

On a definition of the appropriate timing

for surgical intervention in orthognathic sur-

gery. Int J Oral Maxillofac Surg 2014;43:

846–55.

2. Hernandez-Alfaro F, Guijarro-Martinez R,

Molina-Coral A, Badia-Escriche C. Surgery

first in bimaxillary orthognathic surgery. J

Oral Maxillofac Surg 2011;69:e201–7.

3. Hernandez-Alfaro F, Guijarro-Martinez R,

Peiro-Guijarro MA. Surgery first in orthog-

nathic surgery: what have we learned? A

comprehensive workflow based on 45 con-

secutive cases. J Oral Maxillofac Surg

2014;72:376–90.

4. Nagasaka H, Sugawara J, Kawamura H,

Nanda R. Surgery first skeletal class III

correction using the skeletal anchorage sys-

tem. J Clin Orthod 2009;43:97–105.

5. Liou EJ, Chen PH, Wang YC, Yu CC, Huang

CS, Chen YR. Surgery-first accelerated

orthognathic surgery: postoperative rapid

orthodontic tooth movement. J Oral Max-

illofac Surg 2011;69:781–5.

6. Wilcko MT, Wilcko WM, Pulver JJ, Bissada

NF, Bouquot JE. Accelerated osteogenic

orthodontics technique: a 1-stage surgically

facilitated rapid orthodontic technique with

alveolar augmentation. J Oral Maxillofac

Surg 2009;67:2149–59.

7. Cohn-Stock G. Die chirurgische Immediatre-

gulielung der Kiefer, speziell die chirurgische

Behandlung der Prognathie. Viertel-

jahrsschirft Zahnheilk 1921;37:320–54.

8. Hernandez Alfaro F, Guijarro-Martınez R.

New protocol for three-dimensional surgical

planning and CAD/CAM splint generation in

Alfaro F, et al. Inferior subapical osteotomy for

y-early’ orthognathic treatment, Int J Oral M

orthognathic surgery: an in vitro and in vivo

study. Int J Oral Maxillofac Surg 2013;42:

1547–56.

9. Dorfman HS. Mucogingival changes result-

ing from mandibular incisor tooth move-

ment. Am J Orthod 1978;74:286–97.

10. Artun J, Krogstad O. Periodontal status of

mandibular incisors following excessive pro-

clination. A study in adults with surgically

treated mandibular prognathism. Am J

Orthod Dentofacial Orthop 1987;91:225–32.

11. Melsen B, Allais D. Factors of importance

for the development of dehiscences during

labial movement of mandibular incisors: a

retrospective study of adult orthodontic

patients. Am J Orthod Dentofacial Orthop

2005;127:552–61. quiz 625.

12. Aziz T, Flores-Mir C. A systematic review of

the association between appliance-induced

labial movement of mandibular incisors and

gingival recession. Aust Orthod J 2011;27:

33–9.

13. Joss-Vassalli I, Grebenstein C, Topouzelis N,

Sculean A, Katsaros C. Orthodontic therapy

and gingival recession: a systematic review.

Orthod Craniofac Res 2010;13:127–41.

14. Park JU, Hwang YS. Evaluation of the soft

and hard tissue changes after anterior seg-

mental osteotomy on the maxilla and mandi-

ble. J Oral Maxillofac Surg 2008;66:98–103.

15. Morgan TA, Fridrich KL. Effects of the

multiple-piece maxillary osteotomy on the

periodontium. Int J Adult Orthodon Orthog-

nath Surg 2001;16:255–65.

16. Bloomquist DS. Anterior segmental mandib-

ular osteotomies for the correction of facial–

skeletal deformities. Oral Maxillofac Surg

Clin North Am 2007;19:369–79. vi.

Address:Raquel Guijarro-MartınezInstitute of Maxillofacial SurgeryTeknon Medical CentreVilana 12D-18508022 BarcelonaSpainTel: +34 933 933 185E-mail: guijarro.raq@gmail.com

dentoalveolar decompensation of class III

axillofac Surg (2016), http://dx.doi.org/