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| Title |
A Surgery-First Orthognathic Approach to Treatment of Dentofacial Deformities Can Be More Efficient |
| Clinical Question |
In patients with a dentofacial deformity that requires surgical and orthodontic correction, is surgery first followed by orthodontics a more efficient and faster option than the traditional sequence of orthodontic decompensation followed by surgical correction? |
| Clinical Bottom Line |
The surgery-first approach allows for a shorter treatment period than the conventional approach to orthognathic surgeries for patients with a dentofacial deformity requiring surgical and orthodontic correction. This is supported by two systematic reviews and a prospective study. However, their findings do stipulate that there are certain contraindications for the surgery-first approach. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 27021449 | Peiro-Guijarro/2016 | 11 Studies (459 patients; SF = 295; CA = 164)* *SF= Surgery first; CA = Conventional approach | Systematic review of non-randomized trials | | Key results | The 295 patients receiving the surgery-first approach completed their treatment in an average of 14.2 months, roughly 6 months shorter than those (n=164) who were treated with the conventional approach (mean= 20.16 months). The ages of the patients ranged from 16 to 36 years at the time of treatment. The most prevalent type of malocclusion treated was a Class III occlusion (84.7% of surgery-first patients). | | #2) 25116713 | Huang/2014 | 14 Studies (236 Patients) | Systematic review of non-randomized trials | | Key results | Most included studies stated that the completion of treatment with a surgery-first approach was approximately 6-12 months shorter than with the conventional orthodontics-first approach. Several advantages of the surgery-first technique were listed, including the equal or improved stability of treatment results, increased pace of orthodontic treatment, and earlier improvement in patient’s facial esthetics. | | #3) 28043746 | Jeong/2017 | 97 Patients with Class III malocclusions | Prospective Cohort Study | | Key results | The patients were divided into surgery-first groups (n= 45) and orthodontics-first group (n=52). It was concluded that surgery-first patients completed treatment in an average of 13.6 months; this was roughly 8 months less than the conventional approach (mean 21.6 months). Any patients requiring tooth extractions showed no significant difference in treatment times for the two approaches. Overall, those who qualified for and underwent surgery-first treatment without extractions endured a shorter treatment time than those undergoing the traditional approach of orthodontics-first. | |
| Evidence Search |
(("Clinical Protocols"[Mesh] AND ("Dentofacial Deformities/surgery"[Mesh] OR "Dentofacial Deformities/therapy"[Mesh])) AND "Humans"[Mesh]) AND "Orthognathic Surgical Procedures/methods"[Mesh] |
Comments on
The Evidence |
Validity: The Peiro-Guijarro systematic review used an electronic search to find 177 potential papers. Strict inclusion criteria and interrater agreement values (k = 0.89) were then used to narrow down the potential studies to 11 articles to evaluate. There was a large-scale patient base (n=459; CA= 164; SF= 295), a low risk of bias as the same two investigators assessed the quality of all of the studies, and no reported potential conflicts of interest. Huang’s review narrowed the electronic MEDLINE search results of 258 articles to 14 papers using specific inclusion criteria. The papers consisted of 4 cases, 7 case series, and 3 cohort studies for a total of 237 patients. Bias and potential conflicts of interest were not reported. Lastly, the prospective study evaluated 97 Asian patients with class III malocclusion and used pre-surgical simulations to determine the grouping of patients into surgery-first (n = 45) and orthodontic-first (n = 52) groups. There were no conflicts of interests declared and bias was minimized by using strict inclusion and exclusion criteria for the patients chosen.
These papers all found that the surgery first approach significantly reduces treatment time compared to the traditional orthodontics-first approach. However, they all mentioned that surgery-first only works in certain conditions without circumstances that can prevent the alignment of the maxillary and mandibular arches during surgery, such as severe dental crowding, significant facial asymmetry with 3-D dental compensations, severe discrepancies in the arch widths or shapes, etc. There is a longer treatment time for those with unstable occlusion requiring longer or initial orthodontic treatment.
Perspective: Most of the papers on this topic chose to provide the surgery-first approach only to patients with no dental contraindications, such as class III malocclusion patients and without severe dental crowding, significant asymmetries, etc. However, there is still not very much information on how to treat the contraindicated patients besides the suggestion of a “surgery-early” approach where the conventional approach is used with surgery being done very early in the treatment process after a few preliminary orthodontic adjustments. Another limitation in these papers is that the population studied is limited to young adults; there have not been considerations as to how surgeries such as this would affect young or elderly patients. |
| Applicability |
These results are applicable to oral surgeons and orthodontists who treat severe dentofacial deformities, especially Class III malocclusions. It is also applicable to the patient group that is able to be treated by the surgery-first approach, mainly Class III patients with minimal crowding and mild, if any, asymmetries. These patients would not have any interference when repositioning the mandible and/or maxilla. |
| Specialty/Discipline |
(Oral Surgery) (Orthodontics) |
| Keywords |
Surgery-first, orthognathics, treatment outcome, treatment time, Class III malocclusion
|
| ID# |
3165 |
| Date of submission: |
03/21/2017 |
| E-mail |
sarrami@livemail.uthscsa.edu |
| Author |
Shayda Sarrami |
| Co-author(s) |
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| Co-author(s) e-mail |
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| Faculty mentor/Co-author |
Daniel Perez, DDS, MD |
| Faculty mentor/Co-author e-mail |
PerezD5@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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