2014 Winter Conference How We Got Here

February 7-9, 2014

No
Las Vegas, Nevada Oral Maxillofac / Pre-surgical
Plastic Surgery Orthodontics

Point-Counterpoint: Surgery-First Orthognathic

Orthodontics
Pre-surgical
Minimum Pre-Surgical
Surgery Orthodontics
Orthodontics

Point - The Case for Surgical

Orthodontics
Surgery-
First
Surgery-First Orthodontics
Orthodontics TADsNo
(SAS)
Pre-surgical

Junji SUGAWARA Dental / Oral Orthodontics

Implantology
Sendai, Japan Prosthodontics
Sugawara 2014
~1950 1960 1970 1980 1990 2000 2010

Conventional
Surgical Orthodontics
Why Surgery-First?

Initial Imm. before OGS At debonding

Presurgical Orthognathic
Orthodontic Surgery
Treatment (LF1 + BSSO)

What are the Problems? Surgery-First

•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 Initial Imm. after surgery At debonding
commonly expected, with a mean length of 32.8 Orthognathic Postsurgical
months. (O’Brien et al. 2009) Surgery Orthodontics
(BSSO) (SAS)
Styles of Surgery-First Facial Types of Our
Surgery-First Cases (N=162)
Ortho-Driven
To solve skeletal problems 5% Class III patients seem to
with OGS and dental problems
using SAS
8% benefit more from the
(Nagasaka et al. 2009, Villegas et al. 2010,
Surgery-First than Class II
Surgery- Faber 2010, Sugawara et al. 2010) cases.
First (Kim, Mahdavie, Evans 2012)

Surgery-Driven
To solve both skeletal and
dental problems using OGS
87% Class III (141)
(Baek et al. 2010, Liou et al. 2011, Class II (13)
Hernández et al. 2011, Kim et al. 2012)
Class I (8)
As of December 31, 2013

A Recent Point 1: Case Selection

Surgery-First Case Surgery-Driven
Indications of Surgery-First:
1) Crowding: no~mild
2) Curve of Spee: no~mild
3) U1 and L1: normal~mild
4) Asymmetry: no~mild
(Liou et al. 2011)
Ortho-Driven
Indications of Surgery-First:
Most jaw deformities are
indications except for a few
specific types of cases.
(Sugawara 2012)

Ceph Analysis

1. CDS Analysis
Patient 2. Wits Appraisal (-24.0 mm)
YI 20-04 Initial (Sep 30, 2011) Norm
 Ceph Prediction Ceph Prediction
A Initial
Imm. after OGS B Imm. after OGS
At debonding C Initial
At debonding

5 mm

Patient
Norm 4
7
Mx advance: 5 mm 2 5
Mn setback: 10mm
10 mm

Model Prediction for OGS

Point 2: Ceph Prediction 5 mm

There is absolutely no difference

in the way to make cephalometric
predictions between the
conventional approach and the 10.5 m
m
Surgery-First. Only the order of
the procedures is different. Class II denture with open bite reveals the
true extent of decompensation.
(No overcorrection)

Bonding Brackets
Point 3: Model Prediction (.022” slots)

Surgery-Driven Ortho-Driven Passive Surgical

Wires
(.016”x.022” SS)
Occlusion after OGS should Occlusion after OGS should
be setup for “a treatable be setup to reveal the true
Class I malocclusion” with extent of decompensation
tripod occlusal contact. based on ceph prediction.
(Liou et al. 2011) (Nagasaka et al. 2009)

The passive surgical wires were prepared by

a dental technician in a laboratory.
 OGS and SAS
Point 4: TADs
Surgery-Driven Ortho-Driven
Since skeletal and dental The use of the skeletal
problems are solved anchorage system using
LF1 surgically, the application of miniplates or miniscrews is
TADs is not necessarily indispensable in the post-
LF1 + BSSO BSSO required. surgical orthodontics of SF.
SAS miniplates (Nagasaka et al. 2009, )
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)

11 days after OGS (Aug 27, 2012)

Treatment Progress (2) Treatment Progress (3)

3.8 months after OGS (Dec 07, 2012) 8.3 months after OGS (Apr 19, 2013)

9.4 months after OGS (Jun 11, 2013)

5.2 months after OGS (Jan 17, 2013)
 Ceph Superimposition

Initial
At debonding

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

Facial Changes Evaluation of End Result

Initial Imm. after surgery At debonding Treatment Goal End result

Ceph Analysis Comparison Pre and Post

Patient
Norm
At debonding

1. CDS Analysis Before After

2. Wits Appraisal (-2.5 mm) Total Treatment Time: 12.0 months
 Benefits and Benefit 1
Problems The 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)

Benefit 2 Benefit 3
Decompensation can be performed
Facial deformity is immediately effectively and efficiently.
corrected.
(Nagasaka et al. 2009)
In Surgery-First, patients can avoid
Increased tone
the exacerbation of their profiles and of the upper lip to
occlusions. maxillary incisors
Increased tone
of the tongue to
mandibular incisors

Short Group (8.7 mos)

Benefit 4
The total treatment time is much shorter
than in the conventional approach.
Total Treatment Time
25
SF COF
12.7 mos 33.7 mos
Number of Patients

20
(7.5~24.9) (19.2~51.5)
15
N=53 N=47
p<0.001

10

0 ~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~ months Initial Imm. after surgery At debonding
Sugawara et al. (in press)
 Long Group (18.7 mos)
Benefit 5
Tooth movement may be accelerated
after OGS.

“OGS triggers a 3- to 4-month period of

higher osteoclastic activities and
metabolic changes in the dentoalveolus
postoperatively.” (Liou et al. 2011)
Initial Imm. after surgery At debonding

One-Jaw Surgery (BSSO)

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

Initial Imm. after surgery At debonding

Recover from Surgical Error

Benefit 7
In the Surgery-First approach, the
unlikely event of a surgical error
Initial Imm. after surgery
and a possible post-surgical
relapse can be compensated during
the post-surgical orthodontics.

After removal of splint At debonding

 Conclusion
The Problem
Without pre-surgical orthodontics, Benefits
Problem
s
Benefits
it is difficult to obtain a stable Problems

occlusion immediately after OGS.

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
Surgical surgeons must be experienced to predictably achieve
Splint the desired outcome.

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

UCONN SAS Centre

Prof. R. Nanda Dr. H. Momono
Prof. F. Uribe Dr. S. Yamada