2014 Winter Conference February 7-9, 2014 Las Vegas, Nevada Point-Counterpoint: Surgery-First Point - The Case for Surgery-First Junji SUGAWARA Sendai, Japan Oral Maxillofac / Plastic Surgery Prosthodontics How We Got Here Orthognathic Surgery No Pre-surgical Surgical Dental / Oral Implantology Pre-surgical Minimum Pre-Surgical TADs No (SAS) Pre-surgical Surgery- First Sugawara 2014 ~1950 1960 1970 1980 1990 2000 2010 Why Surgery-First? Conventional Surgical Presurgical Orthodontic Treatment Imm. before OGS Orthognathic Surgery (LF1 + BSSO) What are the Problems? The worsening facial profile, some masticatory discomfort during presurgical orthodontics, and long-term low QOL were cited as problems. (Proffit, White, Sarver 2003) Surgery-First Presurgical orthodontic treatment was timeconsuming, 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) Orthognathic Surgery (BSSO) Postsurgical (SAS)
Styles of Surgery-First Ortho-Driven Facial Types of Our Surgery-First Cases (N=162) 5% 8% To solve skeletal problems with OGS and dental problems using SAS SurgeryFirst Class III patients seem to benefit more from the Surgery-First than Class II cases. (Kim, Mahdavie, Evans 2012) (Nagasaka et al. 2009, Villegas et al. 2010, Faber 2010, Sugawara et al. 2010) Surgery-Driven 87% To solve both skeletal and dental problems using OGS Class III (141) Class II (13) Class I (8) (Baek et al. 2010, Liou et al. 2011, Hernández et al. 2011, Kim et al. 2012) As of December 31, 2013 A Recent Surgery-First Case Point 1: Case Selection Surgery-Driven Ortho-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 Indications of Surgery-First: Most jaw deformities are indications except for a few specific types of cases. (Sugawara 2012) (Liou et al. 2011) Ceph Analysis YI 20-04 (Sep 30, 2011) Patient Norm 1. CDS Analysis 2. Wits Appraisal (-24.0 mm)
Ceph Prediction A Imm. after OGS Ceph Prediction C after OGS B Imm. 5 mm Patient Norm 4 7 10 mm Mx advance: 5 mm Mn setback: 10mm 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. Point 3: Model Prediction Surgery-Driven Ortho-Driven Occlusion after OGS should be setup for a treatable Class I malocclusion with tripod occlusal contact. (Liou et al. 2011) Occlusion after OGS should be setup to reveal the true extent of decompensation based on ceph prediction. (Nagasaka et al. 2009) 2 5 Model Prediction for OGS 5 mm 10.5 m m Class II denture with open bite reveals the true extent of decompensation. (No overcorrection) 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 Point 4: TADs Surgery-Driven LF1 + BSSO LF1 BSSO SAS miniplates Ortho-Driven Since skeletal and dental The use of the skeletal problems are solved anchorage system using surgically, the application of miniplates or miniscrews is TADs is not necessarily indispensable in the postrequired. surgical orthodontics of SF. (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) 11 days after OGS (Aug 27, 2012) Treatment Progress (2) 3.8 months after OGS (Dec 07, 2012) 5.2 months after OGS (Jan 17, 2013) 3.1 months after OGS (Nov 16, 2012) Treatment Progress (3) 8.3 months after OGS (Apr 19, 2013) 9.4 months after OGS (Jun 11, 2013)
Ceph Superimposition YI 22-02 (Jul 11, 2013) Facial Changes Evaluation of End Result Treatment Goal End result Ceph Analysis Comparison Pre and Post Patient Norm 1. CDS Analysis 2. Wits Appraisal (-2.5 mm) Before After Total Treatment Time: 12.0 months
Benefits and Problems Benefit 1 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 3 Benefit 2 Facial deformity is immediately corrected. Decompensation can be performed effectively and efficiently. (Nagasaka et al. 2009) In Surgery-First, patients can avoid the exacerbation of their profiles and occlusions. Increased tone of the upper lip to 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 Number of Patients 25 SF COF 12.7 mos (7.5~24.9) N=53 20 15 33.7 mos (19.2~51.5) N=47 p<0.001 10 5 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 Sugawara et al. (in press)
Long Group (18.7 mos) Benefit 5 Tooth movement may be accelerated after OGS. Benefit 6 OGS triggers a 3- to 4-month period of higher osteoclastic activities and metabolic changes in the dentoalveolus postoperatively. (Liou et al. 2011) One-Jaw Surgery (BSSO) In Ortho-Driven style, the range of indications for one-jaw surgery is significantly expanded. Benefit 7 In 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. Recover from Surgical Error After removal of splint
The Problem Without pre-surgical orthodontics, it is difficult to obtain a stable occlusion immediately after OGS. Conclusion Benefits Benefits Problems Problems Surgical Splint 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