Point-Counterpoint: Surgery-First Orthodontics

Point - The Case for Surgery-First Orthodontics

Junji SUGAWARASendai, Japan

2014 Winter ConferenceFebruary 7-9, 2014 Las Vegas, Nevada

~1950 1960 1970 1980 2000 20101990

Surgery- First

Orthodontics

Prosthodontics

Dental / OralImplantology

TADs (SAS)

Surgical Orthodontics

Minimum Pre-Surgical Orthodontics

OrthognathicSurgery

Oral Maxillofac / Plastic Surgery

NoPre-surgicalOrthodontics

NoPre-surgicalOrthodontics

Pre-surgicalOrthodontics

Sugawara 2014

How We Got Here

Why Surgery-First?Conventional

Surgical Orthodontics

Initial Imm. before OGSPresurgical Orthodontic Treatment

At debondingOrthognathic

Surgery(LF1 + BSSO)

•The worsening facial profile, some masticatory discomfort during presurgical orthodontics, and long-term low QOL were cited as problems. (Proffit, White, Sarver 2003)

•Presurgical orthodontic treatment was time-consuming, taking as long as 24 months. (Luther, Morris, Hart 2003)

•Overall treatment duration was longer than commonly expected, with a mean length of 32.8 months. (O’Brien et al. 2009)

What are the Problems?

Imm. after surgery At debondingInitial

PostsurgicalOrthodontics

(SAS)

OrthognathicSurgery(BSSO)

Surgery-First

Styles of Surgery-First

Surgery-DrivenTo solve both skeletal and

dental problems using OGS (Baek et al. 2010, Liou et al. 2011,

Hernández et al. 2011, Kim et al. 2012)

Ortho-DrivenTo solve skeletal problems

with OGS and dental problems using SAS

(Nagasaka et al. 2009, Villegas et al. 2010, Faber 2010, Sugawara et al. 2010)Surgery-

First

Facial Types of Our Surgery-First Cases (N=162)

87%

5%8%

Class III (141)Class II (13)Class I (8)

As of December 31, 2013

Class III patients seem to benefit more from the

Surgery-First than Class II cases.

(Kim, Mahdavie, Evans 2012)

A Recent Surgery-First Case Ortho-Driven

Indications of Surgery-First: Most jaw deformities are indications except for a few specific types of cases.

(Sugawara 2012)

Point 1: Case SelectionSurgery-Driven

Indications of Surgery-First:1) Crowding: no~mild2) Curve of Spee: no~mild3) U1 and L1: normal~mild4) Asymmetry: no~mild

(Liou et al. 2011)

YI 20-04 Initial (Sep 30, 2011)

Ceph Analysis

1. CDS Analysis2. Wits Appraisal (-24.0 mm)Patient

Norm

10 mm

Ceph Prediction

5 mm

InitialImm. after OGS

Mx advance: 5 mmMn setback: 10mm

PatientNorm

A InitialAt debondingC

Ceph Prediction

4

7

52

Imm. after OGSAt debondingB

Point 2: Ceph Prediction

There is absolutely no difference in the way to make cephalometric

predictions between the conventional approach and the Surgery-First. Only the order of

the procedures is different.

Model Prediction for OGS

Class II denture with open bite reveals the true extent of decompensation.

(No overcorrection)

10.5 mm

5 mm

Point 3: Model PredictionSurgery-Driven

Occlusion after OGS should be setup for “a treatable

Class I malocclusion” with tripod occlusal contact.

(Liou et al. 2011)

Ortho-DrivenOcclusion after OGS should be setup to reveal the true extent of decompensation based on ceph prediction.

(Nagasaka et al. 2009)

Bonding Brackets(.022” slots)

Passive Surgical Wires

(.016”x.022” SS)

The passive surgical wires were prepared by a dental technician in a laboratory.

OGS and SAS

SAS miniplates

LF1BSSOLF1 + BSSO

11 days after OGS (Aug 27, 2012)

Ortho-DrivenThe use of the skeletal

anchorage system using miniplates or miniscrews is indispensable in the post-

surgical orthodontics of SF.(Nagasaka et al. 2009, )

Point 4: TADsSurgery-DrivenSince skeletal and dental

problems are solved surgically, the application of

TADs is not necessarily required.

11 days after OGS (Aug 27, 2012)

Immediately after OGS Treatment Progress (1)

0.9 months after OGS (Sep 12, 2012)

3.1 months after OGS (Nov 16, 2012)

Treatment Progress (2)

3.8 months after OGS (Dec 07, 2012)

5.2 months after OGS (Jan 17, 2013)

Treatment Progress (3)

8.3 months after OGS (Apr 19, 2013)

9.4 months after OGS (Jun 11, 2013)

YI 22-02 At debonding (Jul 11, 2013)

Ceph Superimposition

InitialAt debonding

Facial Changes

At debondingInitial Imm. after surgery Treatment Goal

Evaluation of End Result

End result

Ceph Analysis

1. CDS Analysis2. Wits Appraisal (-2.5 mm)

PatientNorm

At debonding

Comparison Pre and Post

AfterBefore

Total Treatment Time: 12.0 months

Benefits and Problems

Benefit 1The timing of OGS is entirely up to

the patient.Since the OGS precedes orthodontic

treatment, the patient has the opportunity to choose the timing of surgery to allow

for the postoperative healing period.(Kim, Mahdavie, Evans 2012)

Facial deformity is immediately corrected.

In Surgery-First, patients can avoid the exacerbation of their profiles and

occlusions.

Benefit 2Decompensation can be performed

effectively and efficiently.(Nagasaka et al. 2009)

Benefit 3

Increased tone of the upper lip to maxillary incisorsIncreased tone of the tongue to mandibular incisors

The total treatment time is much shorter than in the conventional approach.

Benefit 4

0

5

10

15

20

25

~9 9~12 12~15 15~18 18~21 21~24 24~27 27~30 30~33 33~36 36~39 39~42 42~45 45~

Total Treatment TimeSF

12.7 mos(7.5~24.9)

N=53

COF33.7 mos

(19.2~51.5)N=47

months

Num

ber

of P

atie

nts

p<0.001

Sugawara et al. (in press)

Imm. after surgery At debonding

Short Group (8.7 mos)

Initial

Imm. after surgery At debondingInitial

Long Group (18.7 mos)

Tooth movement may be accelerated after OGS.

Benefit 5

“OGS triggers a 3- to 4-month period of higher osteoclastic activities and

metabolic changes in the dentoalveolus postoperatively.” (Liou et al. 2011)

Benefit 6In Ortho-Driven style, the range of indications for one-jaw surgery is

significantly expanded.

Imm. after surgery At debonding

One-Jaw Surgery (BSSO)

Initial

Benefit 7In the Surgery-First approach, the unlikely event of a surgical error

and a possible post-surgical relapse can be compensated during

the post-surgical orthodontics.

Initial Imm. after surgery

After removal of splint At debonding

Recover from Surgical Error

The ProblemWithout pre-surgical orthodontics,

it is difficult to obtain a stable occlusion immediately after OGS.

Surgical Splint

Benefits

ProblemsBenefits

Problems

Conclusion

Although there are two different styles of the Surgery-First approach. Clearly, the benefits of both styles

substantially outweigh the problems associated with them. It must be noted that orthodontists and

surgeons must be experienced to predictably achieve the desired outcome.

Tohoku Univ. Prof. H. Kawamura Prof. H. Nagasaka Prof. S. Goto Prof. T. Takahashi

UCONN Prof. R. Nanda Prof. F. Uribe

SAS Centre Dr. H. Momono Dr. S. Yamada