Rationale, relevance, and efficacy of “surgery first, orthodontics later” approach in the management of cases of severe malocclusion with skeletal discrepancy

Abstract

A good esthetic outcome and optimal functional occlusion is the goal of management of any dentofacial anomaly. Conventional orthognathic surgery, as commonly practiced, entails a rather long-drawn management protocol comprising a triphasic treatment approach, with the surgical procedure being both preceded and followed by pre- and post-surgical orthodontics, respectively. This has numerous well-known drawbacks such as an uncertain and unpredictable patient compliance and poor motivation due to the inevitably long duration of orthodontic therapy; a transient and temporary worsening of the facial appearance brought about by presurgical orthodontic decompensation of occlusal relationships; and the inevitably prolonged time frame involved in ultimately achieving the desired esthetic and functional results. Further, unforeseen interruptions along the course of the long treatment period can result in unfavorable and even disastrous outcomes. The newer concept and technique of “Surgery First Orthodontics After” (SFOA) approach or “surgery-first approach” (SFA) entails first performing orthognathic surgery, thereafter following it up and finishing the case with postsurgical orthodontic settling and correction of the occlusion. It has two very distinct advantages over the erstwhile approach, first, an immediate and early correction of the facial deformity resulting in a remarkable improvement in facial appearance, which in most cases was what had prompted the patient to seek treatment for, in the first place. The patient, encouraged and motivated by the obvious and appreciable esthetic results, complies willingly and well with the subsequent postsurgical orthodontic treatment, even if it is lengthy or inconvenient, thus ensuring an optimal ultimate occlusion with complete functional rehabilitation as well. The second advantage of SFA is a markedly reduced overall treatment time, which is greatly appreciated by the patients. This article presents three cases of severe malocclusion with associated skeletal discrepancies, treated expeditiously and effectively using the SFA protocol. The overviews of SFA, including its rationale and relevance, indications, general and specific guidelines, different protocol variations, clinical outcome and success rate, as well as possible complications and potential problems encountered with this novel treatment protocol are also discussed.

Case Report on Surgery-First Approach

“…Although the SFA has its inherent advantages, several difficulties and challenges still exist. Disadvantages of the technique include the need for predicting the outcome of postoperative orthodontic treatment accurately, especially when planned in two-dimensional plane,[ 4 ] problems of occlusal instability after surgery which can cause skeletal instability,[ 10 ] and increased surgical movement to compensate for the amount of dental decompensation. [ 11 ]…”

Orthognathic Surgery

“…This protocol has been the most widely followed strategy for OGS throughout the world. However, despite favorable results, most patients were required to endure long periods of orthodontic therapy which was not only cumbersome but temporarily compromised their facial appearance (Jeyaraj and Chakranarayan 2019).…”