POST-GRADUATE DEPARTMENT OF ORTHODONTICS &

DENTOFACIAL ORTHOPAEDICS
GOVERNMENT DENTAL COLLEGE AND HOSPITAL
SHIREEN BAGH, SRINAGAR

Seminar on: Surgery First Approach

UNDER THE GUIDANCE OF:

PROF. (DR.) MOHAMMAD MUSHTAQ
Prof. and HOD
Department of Orthodontics and Dentofacial Orthopaedics

Presented by : Dr. Sameer Ahamad Kambay

PG-Student
Contents
 Introduction
 History
 Indications
 Contraindications
 Classification & Styles of SFOA
 Advantages and Disadvantages
 Protocol in SFOA
 Biological Principles and Responses
 Diagnosis & Treatment Planning
 Orthodontic Considerations
 Management of Skeletal Class II Malocclusion
 Management of Skeletal Class III Malocclusion
 Outcome Assessment and Stability
 Conventional vs SFOA
 Conclusion
 References
Introduction
Orthognathic surgery has been one of the most important tools in the correction
of skeletal malocclusions and facial disharmonies. Traditionally, treatment
involves a conventional three-stage sequence:
1. Presurgical orthodontics to align teeth and decompensate dentition
2. Surgical correction of the skeletal discrepancy
3. Postsurgical orthodontics for finishing and detailing
Although effective, this conventional approach poses several limitations:
 Long treatment duration (often exceeding 2–3 years)
 Poor esthetics during presurgical orthodontics due to worsening of dental
compensation
 Risk of decalcification, root resorption, and gingival problems during
extended orthodontic phases
To overcome these drawbacks, the Surgery-First Approach (SFA) was
developed. This protocol bypasses presurgical orthodontics and focuses on
correcting the skeletal problem immediately, followed by postoperative
orthodontics.
Thus, SFOA represents a paradigm shift in orthognathic treatment philosophy,
offering faster esthetic results, improved patient satisfaction, and comparable
stability when executed with proper planning.
Historical Perspective
The concept of performing surgery before orthodontics was introduced in Japan,
particularly with the Sendai approach in the early 2000s. Since then, the
approach has been studied and refined across the world.
 Hernandez-Alfaro & Guijarro-Martínez (2014) defined appropriate
timing for surgical intervention and introduced related terms like surgery
early and surgery last.
 Chng, Gandedkar, Liou (2019) published Surgery-First Orthodontic
Management, a landmark clinical guide.
 Over the last two decades, advances in 3D imaging, virtual surgical
planning, and skeletal anchorage systems have made SFOA more
predictable.
Challenges Associated With Conventional Orthognathic Surgery Cases
 Long treatment times of 7-47 months.
 Increased risk of enamel decalcification.
 Gingival recession and root resorption.
 Esthetic and functional drawbacks during the presurgical orthodontic
treatment.
Indications of SFOA
SFOA is most suitable in patients where skeletal correction is the primary
concern, and minimal dental decompensation is required.
Common Indications:
 Skeletal Class III malocclusions with well-aligned or mildly crowded
anterior teeth
 Patients with flat or mild curve of Spee
 Cases with normal to mildly proclined/retroclined incisors
 High esthetic demands and psychosocial concerns requiring immediate
improvement

Favorable Cases:
 Mild to moderate dental crowding
 Acceptable incisor inclination
 Minimal transverse discrepancies
Unfavorable but Possible Cases (in expert hands):
 Moderate to severe crowding
 Asymmetries with complex 3D compensations
 Cases requiring multiple segmental osteotomies
Contraindications of SFOA
SFOA is not recommended in:
 Severe craniofacial deformities requiring staged correction
 Patients with severe dental crowding that necessitates major presurgical
orthodontic preparation
 Severe vertical or transverse discrepancies
 Class II Division 2 malocclusions with deep bite
 Patients with poor compliance or where splint stabilization cannot be
guaranteed

Classification and Styles of SFOA

Two distinct styles have been described:
1. Orthodontically Driven Style (Sendai Approach)
o Jaw deformity corrected surgically, while dental malpositions
corrected orthodontically.
o First recommended in 2003 at Tohoku University, Sendai, Japan.
2. Surgically Driven Style
o Both skeletal and certain dental problems are addressed primarily
through surgery.
o Requires complex planning and is suitable for more challenging
cases.
Advantages of SFOA
 Immediate Esthetic Improvement: Patients no longer suffer the
psychological burden of worsened appearance during presurgical
orthodontics.
 Reduced Total Treatment Time: Overall duration is shortened by 6–12
months compared to conventional methods.
 Psychosocial Benefits: Earlier correction improves confidence,
compliance, and quality of life.
 RAP Effect: The Regional Acceleratory Phenomenon following surgery
accelerates orthodontic tooth movement.
 Functional Benefits: Early improvement in TMJ symptoms, airway
patency, and masticatory efficiency.
 Flexibility: Postsurgical orthodontics can correct minor surgical
discrepancies or relapse.

Disadvantages of SFOA
 Complex Diagnosis and Planning: Requires extensive collaboration
between orthodontist and surgeon.
 Challenging Occlusion Planning: Setting a surgical occlusion without
decompensated teeth is difficult.
 Immediate Occlusal Instability: Postsurgical occlusion may initially be
unstable.
 Need for Skeletal Anchorage: TADs or miniplates are often required.
 Team Expertise Required: Only suitable for centers with experienced
surgical-orthodontic teams.
 Risk of Relapse: Particularly in large mandibular setbacks or severe open
bite cases.
Protocol in SFOA
Preoperative Procedures
 Bonding Timing: Literature suggests bonding brackets 1–4 weeks before
surgery.
 Sugawara and Nagasaka recommended 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.


 Archwire Selection:
o Some prefer light NiTi wires to initiate movement immediately
after surgery.
o Others use stiff stainless steel wires to stabilize occlusion during
intermaxillary fixation.
o Liou et al did not place any orthodontic archwires before surgery.
o Ching et al used 0.016” x 0.022” superelastic NiTi wire.
o Carlos et al have opted to use 0.16”X0.16” nickel-titanium wires
at time of surgery.
o The use of nickel-titanium wires translates into immediate tooth
movement after surgery which can be an advantage.
 o Sugawara and Nagasaka preferred 0.18”x0.25” SS wires and
0.19”x0.25” SS wires in 0.022 slot are adapted to all teeth for
preventing any tooth movement.
o Full slot withstands the forces resulting from intermaxillary
fixation.
o However, in doing so, the orthodontist loses the opportunity to
observe the stability of the surgical correction prior to starting the
tooth movement.

 Splints:
o Fabricated based on model surgery or virtual planning.
o Can be kept from intraoperative use only to up to 6 weeks
postoperatively depending on stability.
o Either brackets have hooks or brass wire (lugs) are soldered to the
arch wire for wiring fixation, Kobayashi hooks can also be used.
Occasionally, intermaxillary screws may be required
Presurgical orthodontic preparations for the SFA
 Sugawara et al modified the surgical splint into a removable maxillary
occlusal splint, which was used to stabilize the jaw position and
masticatory function.

Surgical Procedures

 Common surgeries include Le Fort I osteotomy, Bilateral Sagittal Split

Osteotomy (BSSO), segmental osteotomies, and genioplasty.
 Increasingly planned with 3D virtual surgical planning (VSP) for
precision.
3D virtual planning LeFort I osteotomy with maxillary advancement, unilateral
impaction on the right, bilateral split sagittal osteotomy with unilateral setback
(right side), and lateral sliding genioplasty in patient with classIII
malocclussion treated with surgery first approach

Postoperative Procedures
 Orthodontic Alignment and Finishing: Begins soon after surgery, aided by
RAP.
 Splint Retention: Ensures stability of occlusion.
 Arch Coordination: Managed postoperatively through elastics, archwires,
and skeletal anchorage.

Biological Principles and Responses

 Regional Acceleratory Phenomenon (RAP):
o Bone turnover and remodeling increase following surgical trauma.
o Results in accelerated tooth movement for 3–4 months post-
surgery.
 Psychological Benefits: Immediate esthetic improvement enhances
compliance and motivation.
  Functional Adaptation: Improved airway, muscle balance, and TMJ
stability post-correction.

Diagnosis and Treatment Planning

 Requires clinical records, photographs, cephalometrics, and CBCT scans.
 Virtual Surgical Planning (VSP) enables simulation of skeletal
movements and fabrication of surgical splints.
 Set-up models used to simulate occlusion and predict outcomes.
 Ideal planning includes establishing a three-point occlusal contact at the
time of surgery.

Management of Skeletal Malocclusions

Class II Cases
 Typically mandibular retrognathism
 Managed with BSSO advancement ± genioplasty
 Postsurgical orthodontics intrudes and aligns teeth for stable occlusion
Class III Cases
 Most common indication for SFOA
 Managed with mandibular setback, maxillary advancement, or both
 Incisor inclination and crowding corrected postoperatively
 Segmental osteotomies or maxillary clockwise rotation may be performed
for esthetics
Stability and Outcome Assessment
 Relapse rates reported higher in SFOA than conventional (up to 27.8% vs
8.6%)
 Most relapse occurs within the first 3 months postoperatively

 Risk factors include:

o Large mandibular setbacks
o Severe open bite correction
o Poor splint compliance
 However, with skeletal anchorage and VSP, long-term outcomes are
increasingly stable.

Conventional vs SFOA
Conventional Approach
  Long duration (often >2 years)
 Esthetics worsens during presurgical phase
 Decompensation orthodontics is time-consuming
SFOA
 Immediate esthetic and psychosocial benefits
 Reduced treatment time
 Requires expert planning, risk of relapse higher if poorly executed

 Orthognathic surgery is coming into a new era of management where

patients and practitioners both benefit.
 As Thomas S. Kuhn, who coined the term ‘paradigm shift’, describes
‘paradigm shift’ as an undeniable discovery that is thoroughly undoing
the accepted knowledge and beliefs and so is SFOA, which has poised
itself to undo the previous conventions with which one should approach
jaw surgery management.
 The scope of this approach has been expanding with advances in 3-
dimensional (3D) imaging technology and 3D virtual surgical simulation,
the use of skeletal anchorage systems, and better understanding of the
biologic response after surgery
 Coordination between specialities, Planning & Case selection is
important.
Conclusion
The Surgery-First Approach represents a paradigm shift in orthognathic
management. With modern advances in imaging, planning, and skeletal
anchorage, SFOA is no longer an experimental concept but a reliable treatment
protocol for selected cases.
While it demands high expertise and careful case selection, its benefits—
reduced treatment time, early esthetic correction, psychological relief, and
enhanced compliance—make it an invaluable option in contemporary
orthodontics and orthognathic surgery.
References
 Proffit WR, White RP, Sarver DM. Contemporary Treatment of
Dentofacial Deformity.
 Hernandez-Alfaro F, Guijarro-Martínez R. Int J Oral Maxillofac Surg.
2014.
 Choi JW, Lee JY. Archives of Plastic Surgery. 2021.
 Hwang HS, Oh MH, Oh HK, Oh H. Am J Orthod Dentofacial Orthop.
2017.
 Zingler S et al. J Craniomaxillofac Surg. 2017.
 Jeong J et al. Int J Oral Maxillofac Surg. 2017.
 Posnick JC. Orthognathic Surgery: Principles and Practice