British Journal of Oral and Maxillofacial Surgery (2003) 41, 401406

2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/S0266-4356(03)00163-3, available online at www.sciencedirect.com

Orthodontic preparation for orthognathic surgery: how long does it take

and why? A retrospective study

F. Luther D. O. Morris, , C. Hart

Senior
Lecturer and Honorary Consultant Orthodontist; Consultant Orthodontist, Leeds Dental Institute,
Clarendon Way, Leeds LS2 9LU, UK; Department of Orthodontics, Seacroft Hospital, York Road, Leeds LS14 6UH,
UK; Dental Surgeon, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, UK

SUMMARY. We investigated the duration of pre-operative orthodontic treatment of patients who had combined
orthodontic and orthognathic treatment and examined the variables that influenced this. Records of patients who
had undergone such treatment in the past 5 years were collected (n = 65) from three consultant orthodontists and
one Senior Specialist Registrar/Fixed Term Training Appointment (FTTA). The number of days from placement
of the first active orthodontic component to the day that final planning impressions were taken was used to cal-
culate the duration of treatment before the patient was ready for operation. The variables investigated were: sex,
age, malocclusion, extractions (excluding third molars), and the clinician. The median duration of pre-operative
treatment was 17 months (range 747). Only the orthodontist appeared to affect this duration, but this requires
further investigation as it may merely reflect variation in other factors such as compliance. We conclude that
patients should be informed that the pre-operative phase may last 1224 months.
2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Osteotomy; Oral surgical procedures and orthodontics, corrective; Treatment outcome and time
factors; Patient education and patient satisfaction

INTRODUCTION
A substantial number of patients require orthognathic op-
erations combined with orthodontic treatment. Indeed, a
recent American study1 suggested that of the 20% of the
population in the USA who have deviations from the ideal
bite, 2% are severe enough to be disfiguring and are at
the limit of orthodontic correction. A survey of British
consultant orthodontists showed that 7% of their caseload
comprised surgical-orthodontic patients.2 However, such
treatment is complex and time-consuming and requires
full cooperation between the parties involved but all of
them require detailed information on which to base their
decisions.
Surgical-orthodontic patients usually express high
levels of satisfaction:3,4 92% (of 139 patients) would rec-
ommend the treatment to a friend or have the operation
again3 and up to 99% report an improvement in appear-
ance, function, or both.3 Other studies,57 however, found
that some patients (whilst satisfied with their appearance
and function) were dissatisfied because of insufficient
preparation for the operation, lack of warnings regarding
factors such as time spent in hospital, dietary changes,
weight loss and time off work. Such studies have shown
the need to keep patients well informed of the procedure
401
and its effects on their lives.6 Few studies have specifi-
cally investigated the orthodontic aspects of orthognathic
surgery. However, Nurminen et al.,8 found that 79% of the
twenty-eight patients who participated in their study re-
ported considerable pain from the orthodontic appliances
and a third of patients rated the orthodontics as the worst
part of their treatment due to the appliances visibility,
discomfort, and the length of orthodontic treatment.
Patients who are given accurate information tend to
be satisfied with their overall treatment.9 The British
Orthodontic Society has published clinical guidelines
on gaining informed consent for orthodontic treatment.
These recommend that patients should receive sufficient
information about the proposed treatment including a
realistic estimate of the timescale involved and the reten-
tion phase of treatment.10 A study of 346 patients who
had had orthognathic surgery,11 reported that the me-
dian total treatment times ranged from 18 to 28 months
depending on the working environment (practice or uni-
versity) and the experience of the operator but there was
no link between extraction patterns and duration of treat-
ment. Other factors (such as missed appointments) that
can influence routine orthodontic treatment duration12,13
were not investigated and no statistical analysis was
presented.
402 British Journal of Oral and Maxillofacial Surgery
In contrast, a Norwegian study14 found the median du-
ration of pre-operative orthodontics to be 15.4 months
(range 392). The factors that significantly increased treat-
ment time included extractions, orthodontists who had
completed fewer than 10 orthognathic cases in the study
time period, patients aged under 40 years and patients
treated outside the university clinic.
Other factors that increase duration of treatment during
conventional orthodontic treatment are extractions and the
severity of the malocclusion. However, such comparisons
must be tempered to some extent, as the tooth movements
required for orthognathic cases are often opposite to those
used for conventional orthodontics.15
Ultimately, the expected duration of treatment is rele-
vant to planning the delivery of services but also allows
the patient to make an informed choice when deciding
whether to accept treatment. The importance of good
information has been emphasised by workers such as
Cunningham et al.9 They stated that post-operative dis-
satisfaction is rarely related to the technical skill of the
surgeon but rather to a failure to communicate. They
also advocated the accurate description of all aspects of
treatment to the patient.
Our purpose in this study was to assess retrospec-
tively the duration of pre-operative orthodontics in pa-
tients who required orthognathic surgical correction
and to identify any influential treatment variables. Dif-
ferences in this duration from the following variables
were examined: extraction compared with non-extraction
(excluding the extraction of third molars); different
types of malocclusion (II/1, II/2, III); sex and age and
orthodontist.
PATIENTS AND METHODS
Ethical approval was sought and granted from the Leeds
Health Authority/United Leeds Teaching Hospitals Re-
search Ethics Committee. Orthodontists involved in the
treatment of combined orthodontic-orthognathic patients
at the Leeds Dental Institute, St. Jamess University
Hospital or Seacroft Hospital, Leeds were contacted
and asked to supply a list of all the orthognathic pa-
tients that they had treated over the past 5 years. The
orthodontists comprised three consultants and one Senior
Specialist Registrar/Fixed Term Training Appointment
(FTTA) undergoing training. One consultant and the
FTTA were able to supply details of patients from a
computerised database, the other operators using com-
puterised clinic and theatre logbooks as their data source.
Laboratory worksheets were also used as a further
check. Two consultant maxillofacial surgeons did all the
operations.
A total of 65 patients were included in the study. The
patients notes were retrieved and used to obtain infor-
mation about: the malocclusion (as stated in the notes
and assumed to be the British Standards Institute incisor
classification, British Standard 4492); the patients date
of birth and sex; teeth extracted as part of the orthodon-
tic treatment (excluding third molars); extractions were
simply recorded as having been undertaken or not and
the number and type of teeth extracted was not recorded
as the sample size was too small to warrant further
subdivision; date on which the first active orthodontic
component was placed; and end of pre-operative or-
thodontics (date on which the patient had final planning
impressions and radiographs taken). These appointments
were timed to allow laboratory work to take place before
operation but also to take account of hospital surgi-
cal waiting times of roughly 68 weeks. Patients with
cleft lip or palate and other craniofacial anomalies were
excluded.
The information was collated and analysed using SPSS
for Windows Version 9.0, (SPSS, Chicago, IL). The pro-
gram allowed calculation of the duration of pre-operative
treatment duration in days, which was then converted to
months. Using dates for starting and finishing described
previously gave the duration of active tooth movement.
To confirm the computers calculation of duration of
treatment an error calculation was made. This involved
checking the duration by hand and comparing it with the
computer in a sample of six cases (roughly 10% of the
final sample size).
We aimed to identify covariates that could influence
the length of time taken to prepare a patient orthodonti-
cally for orthognathic surgery, and therefore we applied
descriptive statistics (including box and whisker plots).
Comparison of box and whisker plots allows visual
comparison of the median and spread and can therefore
highlight areas of potential interest for future prospective
work. In a box and whisker plot, the box marks the in-
terquartile range; the horizontal line across the box shows
the median. The whiskers extend from the box to the
highest and lowest values unless outliers exist (which are
marked by circles and crosses). Circles identify values
between 1.5 and 3 box lengths from the edge of the box;
crosses mark extreme values more than 3 box lengths
away from the edge of the box.
RESULTS
The error calculation showed that the computer spread-
sheet generated duration of treatment in days with 100%
accuracy.
The mean age of the 65 patients at the start of treat-
ment was 22.7 years (range 13.149.5). Only 18 (28%)
of the patients were male and 47 were female (72%).
Table 1 shows the median duration of pre-operative
treatment in months for the total group and also for
 Orthodontic preparation for orthognathic surgery 403

Table 1 Numbers of patients within each class of malocclusion investigated, numbers of patients who had had extractions as part of the treatment
plan and the duration of pre-operative treatment

Variable Number of Percentage Median of Range of

patients pre-operative treatment duration of
duration (months) treatment (months)

Total 65 100 17 747

Class of malocclusion
II division 1 20 31 16 1047
II division 2 6 9 16 922
III 39 60 18 734
Extractions
Yes 21 32 17 1147
No 44 68 17 729

the groups divided according to the malocclusion and 50

Treatment Duration In Months

extractions. The median was used as the data were 17

skewed. 40
The considerable overlap of the boxes in Fig. 1 shows
that there was little difference in the duration of treatment o 54
between those patients who had extractions as part of their 30
orthognathic treatment and those who did not. Figure 2
shows that there was no difference in duration of treatment
20
for the different malocclusions.
Other factors that might contribute to duration of
treatment were examined in the same way. The results 10
for sex and age at the start of treatment and operating
orthodontist are shown in Figs 35. Of these, the reduced 0
overlap of the interquartile range box (for operator 2) N= 20 6 39
II/1 II/2 III
indicates that the duration of treatment of the five pa-
tients treated by this operating orthodontist may show a Presenting Malocclusion
statistically significant difference but this could not be
confirmed. This possibility, therefore, requires further Fig. 2 Box and whisker plots of duration of pre-surgical treatment
showing the effect of malocclusion on overall duration of treatment.
investigation.

50
50
17
17
Treatment Duration In Months
Treatment Duration In Months

40 40

30 30

20 20

10 10

0 0
N= 44 21 N= 18 47
no yes Male Female

Extractions Sex

Fig. 1 Box and whisker plots of duration of pre-surgical treatment to Fig. 3 Box and whisker plots of duration of pre-surgical treatment
show the effect that extractions have on overall duration of treatment. showing the effect of sex on overall duration of treatment.
404 British Journal of Oral and Maxillofacial Surgery

50

40
Treatment Duration In Months

54
30

20

10

0
N= 34 18 10 3
<20 20-29.9 30-39.9 >40

Age Range In Years

Fig. 4 Box and whisker plots of duration of pre-surgical treatment showing the effect of age on overall treatment.

50 account of hospital surgical waiting times and to allow

17 for laboratory work. The usual estimate of duration of
Treatment Duration In Months

treatment may be too optimistic and it would be better to

40 give patients a more realistic expectation.

30 45 The effect of extractions on duration of treatment

Fink and Smith found that routine orthodontic patients
20 who had had extractions needed a mean of 4 months
longer than those who had not had extractions.15 Dowling
10 et al.14 found that extractions added 5 months to the me-
dian pre-operative duration of orthognathic treatment, and
this was significant (P < 0.001). However, we recorded a
0 No. 1 No. 2 No. 3 No. 4
N= 37 5 14 9
difference of only 0.3 months. This would not be of great
clinical importance but the sample was defined only ac-
Operating Orthodontist cording to whether extractions had been carried out or not
(only 5 of the 21 patients had four premolars extracted).
Fig. 5 Box and whisker plots of duration of pre-surgical treatment The number and type of teeth extracted was variable and
showing the effect of different orthodontists on overall duration of
treatment. often a reflection of the patients past dental history or
previous orthodontic experience.

DISCUSSION The effect of malocclusion on duration of treatment

It is inappropriate to compare our group with those re-
Duration of treatment
ported by Fink and Smith15 as the tooth movements re-
This was longer than had been indicated to the patient quired for conventional orthodontics are not the same as
according to the notes (roughly 1215 months). Dowling for surgical orthodontics. They also assessed the severity
et al.14 reported similar figures to those reported here: of the malocclusion before treatment (ANB angle, Salz-
their median duration of pre-operative orthodontics was mann index and angle of the maxillary-mandibular plane).
15 months (range 392) and in the present study the me- Using incisor classification (as we did) is a fairly crude
dian was 17 months (range 747). This excludes a delay way of dividing the patients. Nevertheless, the fact that
(of roughly 68 weeks) before the osteotomy, to take operation was required to correct the malocclusion indi-

cates the severity of the malocclusion, even though this
did not take into account specific vertical skeletal discrep-
ancies, levels of crowding, or spacing. These are all areas
that require further investigation and have received little
attention elsewhere. In our series, patients treated for class
II division 1 or division 2 malocclusions took about the
same time (median 16 months) while the patients in class
III tended to take slightly longer (median 18 months).
However, there was much variation in all three classes of
malocclusion. As there were only six patients who were
given orthognathic treatment for a class II division 2 mal-
occlusion, it is difficult to confirm whether this is an ac-
curate reflection of duration of treatment for this group as
a whole.
Other variables
Neither age nor sex had a significant bearing on the dura-
tion of treatment. Only the orthodontist may have a signif-
icant effect. This would be an interesting area to examine
further but there could be many reasons for this apart
from simple lack of skill or otherwise. For example, op-
erator 2 undertook most clinical work elsewhere so lack
of practice was not necessarily an appropriate explana-
tion as those cases were not included. There may also be
variation in intervals for appointments between orthodon-
tists (for example, from variations in workload) although
in this case, all operators tended to work to 57-week
intervals between appointments. Also, small samples
may give unrepresentative data; this sample included two
transferred patients and a patient who required restorative
collaboration. It is accepted that such factors lengthen
treatment. In addition, other between-operator factors
such as non-compliance by patients, complexity of treat-
ment and whether the orthodontist thought that operation
would be best done early or late16 were not investigated.
The extent to which orthodontic treatment should be
completed before or after operation is controversial. It has
been suggested16 that if the operation is done earlier dur-
ing the orthodontic phase of treatment, then advantages
include the possibility that treatment may be quicker.
However, we know of no randomized, controlled clinical
trial that has been done to confirm this,16 and a recent
study17 suggested that one of the most important factors
that orthodontists use to decide when a case is ready for
operation is correct torque of the anterior teeth. This is
likely to take time to achieve and may also contribute to
the duration of pre-operative orthodontic treatment.
The aim of this study was not to predict the total du-
ration of treatment, but merely to assess one aspect of
duration of orthodontic treatment. It should be appre-
ciated that from the patients perspective other factors
may apparently lengthen the pre-operative duration. For
example, many patients will have had some orthodontic
intervention earlier in life and, even when patients are
Orthodontic preparation for orthognathic surgery 405
identified as having the potential to benefit from this type
of treatment, they may have to be reviewed several times
before it can be confirmed that they have stopped growing
and that they want treatment.
However, reports about the duration of orthodontic
treatment are few and those studies that are available
may not be directly comparable because of variation in
the interpretation of start and finish dates for the period
of pre-operative orthodontics; use of medians rather than
means; and operators experience. In our study, all clin-
icians were consultants or in senior specialist training,
working in the same hospital and university.
There are several limitations to the present study.
These are largely because data were collected retro-
spectively. For example, there was no single, complete
database of patients who had undergone orthognathic
treatment. Consequently some patients could have been
missed. However, this is unlikely: patients appointments
at all the units except one were computerised but that unit
used a database for logging all orthognathic cases. Also,
theatre logbooks (and laboratory technical worksheets)
were checked to confirm completeness of the data.
Information was taken from the patients clinical notes.
Handwriting and abbreviations made the data more diffi-
cult to collect and required thorough reading particularly
where treatment plans changed regarding extractions.
A statistical power calculation to calculate the num-
ber of cases required to show any significant difference
(should one exist) was not made because of the limited
research in this area and the fact that the sample size
was restricted by the number of cases provided by the
orthodontists involved.
On the other hand, the population of Leeds is currently
over 715,000 and the patients attending are likely to be
representative of most large conurbations, not only in the
UK. Nevertheless, this is an area that would benefit from
further work, particularly as we are in an era when patients
rightly demand better information. We therefore suggest
the following improvements: studies should ideally be
prospective and use complete data from a large number
of experienced operators, which would be helped by rou-
tine use of databases to allow comprehensive collection
of data; estimates of sample size and a better assess-
ment of the effects of other variables such as complexity
of treatment and patients compliance. The use of an
agreed, standard dataset (leading to the development of a
comprehensive database) is now being pursued in Leeds.
ACKNOWLEDGEMENT
We thank the orthodontists and oral and maxillofacial surgeons who
agreed to this study being undertaken and to the orthodontic reception
staff at the Leeds Dental Institute, St. Jamess, and Seacroft Hospitals
who helped retrieve the records. We also thank Brett Scaife (Sub-Unit
of Medical Statistics, University of Leeds) for his statistical help and
advice.
406 British Journal of Oral and Maxillofacial Surgery
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HISTORICAL CASE
MORITZ HEINRICH VON ROMBERG
(17951873)
German neurologist. Most famous eponym: (Parry)-Romberg Syndrome, a
rare disorder characterised by progressive hemifacial atrophy, that can some-
times extend to other parts of the body.
14. Dowling PA, Espeland L, Krogstad O, Stenvik A, Kelly A.
Duration of orthodontic treatment involving orthognathic surgery.
Int J Adult Orthodon Orthognath Surg 1999; 14: 146152.
15. Fink DA, Smith RJ. The duration of orthodontic treatment. Am J
Orthod Dentofacial Orthop 1992; 102: 4551.
16. Lee RT. The benefits of post-surgical orthodontic treatment. Br J
Orthod 1994; 21: 265274.
17. Cain KK, Rugh JD, Hatch JP, Hurst CL. Readiness for
orthognathic surgery: a survey of practitioner opinion. Int J Adult
Orthodon Orthognath Surg 2002; 17: 711.
The Authors
F. Luther BDS (Hons), MSc (Lond), PhD (Leeds),
D Orth, M Orth, FDS RCS (Eng)
Senior Lecturer and Honorary Consultant Orthodontist
D. O. Morris BDS, FDS (Orth) RCPS, MSc (Lond),
M Orth RCS (Eng)
Consultant Orthodontist
Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, UK
Department of Orthodontics
Seacroft Hospital, York Road
Leeds LS14 6UH, UK
C. Hart BChD (Hons)
Dental Surgeon
Leeds Dental Institute, Clarendon Way
Leeds LS2 9LU, UK
Correspondence and requests for offprints to: F. Luther BDS (Hons),
MSc (Lond), PhD (Leeds), D Orth, M Orth, FDS RCS (Eng), Senior
Lecturer and Honorary Consultant Orthodontist, Leeds Dental
Institute, Clarendon Way, Leeds LS2 9LU, UK. Tel.: +44 (0) 113
2336138; Fax: +44 (0) 113 2336140; E-mail: F.Luther@Leeds.ac.uk
Accepted 24 July 2003
Moritz Romberg studied medicine in Berlin and obtained his doctorate in
1817 with a thesis on congenital rickets. He gained postgraduate experience in
Vienna, and developed an interest in neurology. After his return from Vienna,
he can be credited with the appointment of the first clinical neurologist. Dur-
ing the cholera epidemics in Berlin in 1831 and 1837, he worked unselfishly
in charge of the cholera hospitals. In 1845, he was given the Chair of Spe-
cial Pathology and Therapy and Directorship of the Royal Policlinic. He then
gave up his position as physician to the poor to concentrate on teaching and
scientific work. Romberg derived much of his background from contempo-
rary English neuroanatomy and neuropathology by translating many works,
including Sir Charles Bells The Nervous System of the Human Body. He
was conscious of the importance of having brought Bells great landmark in
neurology to the German-speaking world.
Romberg was the first physician in history to pay particular attention to al-
tered structure related to clinical manifestations. His clinic was always well
attended and he introduced practical demonstrations that emphasised the im-
portance of a careful physical examination to ensure a correct diagnosis. In this
teaching, he used patients from both his private and impoverished practice.
His most important work was in neuropathology and he published a definitive
three-volume textbook, that was written between 1840 and 1846, while he
was Director of the University Hospital in Berlin. This book was a milestone
because it was the first systematic textbook in neurology. In 1851, Romberg
became medical privy councillor. He died from chronic heart disease in 1873,
at the age of 78 years.
1. von Romberg M. Trohoneurosen. In: Klinische Ergebrice. Berlin: Fostner,
1846: 7581.
P. A. Brennan