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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 112-118

Clinical outcome assessment of surgery first orthodontics after approach for skeletal malocclusions: A pilot study


1 Department of Dental Surgery and Oral Health Sciences, AFMC, Pune, Maharashtra, India
2 Classified Specialist (Orthodontics), CMDC (NC), Meerut, Uttar Pradesh, India
3 Classified Specialist (Orthodontics), MDC, Meerut, Uttar Pradesh, India
4 Army Dental Centre (R and R), New Delhi, India

Date of Submission09-Dec-2021
Date of Decision30-Jan-2022
Date of Acceptance14-Jul-2022
Date of Web Publication21-Dec-2022

Correspondence Address:
Shiv Shankar Agarwal
Classified Specialist (Orthodontics), MDC, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodd.jodd_45_21

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  Abstract 


Background: To investigate treatment outcome of skeletal malocclusion managed employing SFOA.
Material and Methods: The study sample (n=10) requiring mandibular orthognathic surgery was categorised as Group 1 (GP 1) – Skeletal Class II & Group 2 (GP 2) – Skeletal Class III. Pre (T0) and post (T1) treatment records were analyzed using the CCA Index to assess the clinical outcome of the treatment. Lateral cephalogram was analyzed using WITS Appraisal and McNamara analysis to quantify treatment changes. The total duration of treatment was recorded from the case records of patients. Pain perceived by the patients was assessed using Visual Analogue Scale (VAS) after 03 days of surgical procedure, 03 weeks and 03 months.
Results: Mean change in SNB angle was significantly higher in Group 2 compared to Group 1 (P value<0.05). The mean change in ANB angle was significantly higher in Group 1 compared to Group 2 (P value<0.05). The mean change in facial aesthetics score and dental aesthetics score did not differ significantly between two study groups (P value>0.05). For both groups, mean pain response on 3rd day post-surgery was moderate to severe on the VAS which improved to mild to moderate by 3rd week and after 3 months majority of the patients had no pain. The mean total treatment duration from surgery to orthodontic finishing and detailing was 12.2 months, with a range of 8.4 months to 14.6 months.
Conclusions: SFOA results in an immediate and marked improvement in skeletal component of the malocclusion along with significantly improved facial and dental aesthetics.

Keywords: Orthognathic surgery, surgery first orthodontics after, surgery first approach


How to cite this article:
Datana S, Sharma M, Agarwal SS, Bhandari SK. Clinical outcome assessment of surgery first orthodontics after approach for skeletal malocclusions: A pilot study. J Dent Def Sect. 2022;16:112-8

How to cite this URL:
Datana S, Sharma M, Agarwal SS, Bhandari SK. Clinical outcome assessment of surgery first orthodontics after approach for skeletal malocclusions: A pilot study. J Dent Def Sect. [serial online] 2022 [cited 2023 Jan 31];16:112-8. Available from: http://www.journaldds.org/text.asp?2022/16/2/112/364523




  Introduction Top


Skeletal malocclusions form a major part of the incidence of malocclusions in the country. Mandibular skeletal deformities are prevalent as compared to maxillary deformities. These skeletal deformities require surgical intervention for the correction of both form and function, if not intervened during the growth phase of an individual. The conventional orthognathic approach consists of preoperative orthodontic treatment (Pre-OP-OT), orthognathic surgery, and postoperative orthodontic treatment (Post-OP-OT). In this approach, the initial phase of presurgical orthodontics includes leveling and aligning the arches, relieving crowding, decompensating the dentition, coordinating upper and lower arches, and removing occlusal interference.[1] The average time taken to achieve the goals of presurgical orthodontics is 6 months to 2 years.[2],[3] The disadvantage of this approach is orthodontic interventions before orthognathic surgery requiring a long treatment time and may result in a worsening of facial appearance temporarily. However, an alternate approach to achieve immediate facial change has become popular in the recent past “Surgery First Orthodontics After” (SFOA), in this approach, the presurgical orthodontic treatment phase is eliminated or greatly reduced, the jaws are surgically repositioned into the desired positions, and orthodontic tooth movement follows. Patients appreciate the immediate improvement in facial appearance while the orthodontist can utilize the increased bone turnover to achieve accelerated tooth movement. This approach proposes to overcome the disadvantages of conventional surgical-orthodontic treatment procedures[4],[5] with some advantages, such as short total treatment duration, early improvement of the facial profile, establishment of proper maxilla-mandibular relationship before orthodontic treatment, and psychological benefits to the patient.[6],[7]

There is an increase in the trend for adult patients reporting to orthodontic clinics for the treatment of malocclusion and often require correction of underlying skeletal discrepancy. These patients desire their treatment to be completed at the earliest due to social and esthetic concerns.[8] Surgery first approach for the management of orthosurgical cases can meet the requirement of these adult patients. Although there are several case reports/case series and studies published on the various aspects of this new approach, the clinical outcome assessment for the results has not been investigated. The present study was planned to investigate the treatment outcome of skeletal malocclusion managed employing SFOA using a comprehensive clinical assessment (CCA) index and lateral cephalogram. Furthermore, the total treatment duration from surgery to orthodontic finishing and detailing of occlusion and pain perceived during treatment was analyzed.


  Materials and Methods Top


The present prospective clinical study was planned and executed at the department of orthodontics and dentofacial orthopedics of a tertiary care government hospital. The sample consisted of patients who reported to the outpatient department for orthodontic treatment requiring orthognathic surgery, i.e., surgical mandibular advancement/mandibular setback for correction of underlying skeletal malocclusion. The inclusion criteria were patients in permanent dentition (age ≥18 years) with mild crowding (requiring no therapeutic extractions) and with Class II or Class III skeletal malocclusion requiring surgical correction by mandibular advancement/setback. The exclusion criteria were patients with skeletal open bite, compromised periodontal status, a medically compromised condition deemed unfit for surgery, with a history of orthodontic treatment, or syndromic cases including patients with cleft lip and palate.

The study was reviewed and approved by the institutional ethical committee (letter no IEC/2018/49), and participants were explained about the nature and scope of the study, and an informed was obtained from each participant before initiation of treatment. Being a pilot project, a convenient sample size of ten patients was decided in consultation of the statistician of the institute. Patients selected were grouped into two categories (five patients each):

Group 1 (GP 1) – Skeletal Class II

Group 2 (GP 2) – Skeletal Class III

Standard orthodontic pretreatment records (T0): Photographs (extraoral and intraoral photographs), radiographs (orthopantamogram, and lateral cephalogram), cone-beam computed tomography of the maxilla/mandible, and dental models were obtained. All selected patients were thoroughly evaluated, and a customized treatment plan was tailored for each patient, finalized in consultation with the oral and maxillofacial surgical team. “Paper Surgery” (Surgical Treatment objective, STO) planned was emulated on the articulated models (model surgery) of the patients, and an acrylic surgical splint was fabricated. All patients were taken up under general anesthesia and a planned mandibular surgical procedure was executed. Acrylic surgical splint was used during the surgical procedure to position the mandible in the desired position. The splint was cemented on the maxillary dentition after 7 days of surgical procedure to guide the mandible and reprogram the muscles and establish the sensory engram for the first 2 weeks, postsurgery. In the 3rd week, 0.018-inch Roth preadjusted edgewise appliance was bonded, and a conventional wire sequence was followed till finishing, and detailing of occlusion was achieved. Orthodontic appliance was removed once the objectives for the specific case were achieved. Pre (T0) and post (T1)-treatment records of the patients were analyzed using the CCA index to assess the clinical outcome of the treatment. Lateral cephalogram was analyzed using Wits appraisal and McNamara analysis to quantify changes resulted from the treatment. The total duration of treatment was recorded from the case records of patients. Pain perceived by the patients was assessed using the visual analogue scale (VAS)[9] after 03 days of surgical procedure, 03 weeks, and 03 months.

Statistical analysis

The data on categorical variables are shown as n (% of cases). The paired statistical comparison of the distribution of categorical variables was done using Wilcoxon's signed-rank test (nonparametric test for paired ordinal data). In the study, the P < 0.05 was considered to be statistically significant. All the hypotheses were formulated using two-tailed alternatives against each null hypothesis (hypothesis of no difference). The data were statistically analyzed using the Statistical Package for the Social Sciences (SPSS version 22.0, IBM Corporation, Armonk, NY, USA) for MS Windows.


  Results Top


Ten patients (five female and five male), mean age of 21 years (range: 18–23 years), five patients with skeletal Class II and five with skeletal Class III malocclusion with orthognathic maxilla were managed with the SFOA approach.

The mean SNB angle among GP 1 at T1 was (81.00° ± 0.71°) significantly higher compared to T0 (75.8° ± 0.84°) (P < 0.05), mean ANB angle at T1 (1.00° ± 0.71°) was significantly lower compared to T0 (5.80° ± 0.84°) (P < 0.05), and mean mandibular plane angle at T1 (24.40° ± 2.51°) was significantly higher compared to T0 (21.60° ± 3.29°) (P < 0.05) [Table 1] and [Figure 1]. Whereas the mean SNB angle among GP 2 at T1 (80.60° ± 1.14°) was significantly lower compared to T0 (85.80° ± 1.79°) (P < 0.05), mean ANB angle at T1 (0.80° ± 0.84°) was significantly higher compared to T0 (−4.20° ± 0.45°) (P < 0.05), and mean mandibular plane angle at T1 (24.60° ± 4.04°) was significantly lower compared to T0 (27.20°±4.55°) (P < 0.05) [Table 1] and [Figure 1].
Figure 1: Intragroup distribution of mean angular cephalometric parameters

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Table 1: Distribution of mean cephalometric parameters

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Mean effective mandibular length among GP 1 at T1 (100.60 ± 1.67 mm) was significantly higher compared to T0 (95.00 ± 1.58 mm) (P < 0.05), mean pogonion to nasion perpendicular at T1 (−1.80 ± 0.84 mm) was significantly lower compared to T0 (−7.00 ± 0.71 mm) (P < 0.05), mean lower incisor to A-Pog line at T1 (3.80 ± 0.84 mm) was significantly lower compared to T0 (6.00 ± 0.71 mm) (P < 0.05), and mean Wits at T1 (1.60 ± 0.55 mm) was significantly lower compared to T0 (5.80 ± 0.84 mm) (P < 0.05) [Table 1] and [Figure 2]. However, the mean effective mandibular length for GP 2 at T1 (103.40 ± 1.34 mm) was significantly lower compared to T0 (108.80 ± 1.30 mm) (P < 0.05), mean pogonion to nasion perpendicular at T1 (−6.00 ± 1.41 mm) was significantly lower compared to T0 (−2.00 ± 0.71 mm) (P < 0.05), mean lower incisor to A-Pog line at T1 (3.40 ± 0.89 mm) was significantly higher compared to T0 (2.80 ± 0.84 mm) (P < 0.05), and mean Wits at T1 (2.00 ± 0.71 mm) was significantly higher compared to T0 (−3.60 ± 1.14 mm) (P < 0.05) [Table 1] and [Figure 2].
Figure 2: Intragroup distribution of mean linear cephalometric parameters

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The mean change in SNB angle was significantly higher in GP 2 compared to GP 1 (P < 0.05), whereas the mean change in ANB angle was significantly higher in GP 1 compared to GP 2 (P < 0.05). The mean change in mandibular plane angle was significantly higher in GP 2 compared to GP 1 (P < 0.05) [Table 1] and [Figure 3]. Whereas mean change in effective mandibular length, pogonion to nasion perpendicular was significantly higher in GP 2 compared to GP 1 (P < 0.05). Whereas mean change in the lower incisor to A-Pog line and Wits was significantly higher in GP 1 compared to GP 2 (P < 0.05) [Table 1] and [Figure 4].
Figure 3: Intergroup distribution of mean change in angular cephalometric parameters

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Figure 4: Intergroup distribution of mean change in linear cephalometric parameters

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The distribution of mean facial esthetics score, dental esthetics score, vertical control score, arch form score, and treatment efficiency score for GP 1 at T1 was significantly higher compared to the mean score at T0 (P < 0.05). The distribution of mean periodontium management at T1 did not differ significantly compared to the mean score at T0 (P > 0.05). The distribution of the mean root structure preservation score at T1 was significantly lower compared to the mean score at T0 (P < 0.05) [Table 2] and [Figure 5]. However, the mean facial esthetics score and dental esthetics score among GP 2 at T1 were significantly higher compared to the mean score at T0 (P < 0.05). Furthermore, the mean vertical control score, arch form score, and treatment efficiency score at T1 were significantly higher compared to the mean score at T0 (P < 0.05). Mean periodontium management at T1 did not differ significantly compared to the mean score at T0 (P > 0.05) and the mean root structure preservation score at T1 was significantly lower compared to the mean score at T0 (P < 0.05) [Table 2] and [Figure 5].
Figure 5: Intragroup distribution of mean CCA parameters. CCA: Comprehensive clinical assessment

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Table 2: Distribution of mean comprehensive clinical assessment parameters

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The distribution of mean change in facial esthetics score and dental esthetics score did not differ significantly between the two study groups (P > 0.05). Furthermore, the mean vertical control score, arch form score, periodontium management score, root structure preservation score, and treatment efficiency score did not differ significantly between the two study groups (P > 0.05) [Table 2] and [Figure 6]. The mean pain response was statistically significant among the patients at the three intervals studied, response on 3rd day postsurgery was moderate to severe on the VAS which improved to mild to moderate by 3rd week, and after 3 months majority of the patients had no pain [Table 3]. The mean total treatment duration from surgery to orthodontic finishing and detailing was 12.2 months, with a range of 8.4–14.6 months.
Figure 6: Intergroup distribution of mean change in CCA parameters. CCA: Comprehensive clinical assessment

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Table 3: Distribution of pain responses at 3 days, 3 weeks, and 3 months

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  Discussion Top


Orthognathic surgery first performed by Hullihen in 1849,[10] with the introduction of sagittal split osteotomy, has become a mainstay treatment for the correction of dentofacial deformity.[11] The conventional surgical-orthodontic treatment for the management of skeletal malocclusions consists of three phases: Pre-OP-OT, orthognathic surgery, and Post-OP-OT. Although these treatment procedures generally produce satisfactory results, including appropriate dental de-compensation, proper arch coordination, and accurate prediction of surgical results before orthognathic surgery, however, several disadvantages have been reported.[6]

The presurgical orthodontic part of this conventional treatment has been reported to be the most time-consuming part of treatment,[12] a mean length of 7–47 months.[3] This long Pre-Op-OT phase can potentially aggravate the side effects of orthodontic therapy such as dental caries and periodontal problems and also negatively influence the compliance of the patient by worsening of facial profile of the patient. These shortcomings associated with the conventional approach have given rise to a new concept called SFOA, introduced by Brachovogel in 1991. It has been claimed that dental movements following SFOA are achieved on corrected skeletal base without interfering with the compensatory biological response, thereby minimizing relapse after treatment.[13]

The reduced treatment time has been a major factor in the success of SFOA. It has been shown that orthodontic treatment time decreases using alveolar osteotomy procedures.[14] This can be attributed to increased cortical bone porosity after the mechanical alteration of bone, resulting in decreased resistance to tooth movement. It has been shown that during the healing process after orthognathic surgery, there is an increase in blood flow above the presurgical levels.[15] The increase in blood flow facilitates the healing process and stimulates bone turnover which can potentially speed up orthodontic tooth movement.

The CCA was developed at Indiana University to supplement the American Board of Orthodontics objective grading system,[16] has been suggested to have a potential to develop into a “gold standard” for evaluation of treatment outcome, also is the only assessment index that helps to audit facial changes achieved.[17] Hence, CCA was used in the study to evaluate the outcome of the surgery first approach. Although CCA has been proved to be more sensitive than other systems for evaluation of treatment outcomes, especially in mixed dentition, no study has used CCA for evaluation of same using surgery first approach. Hence, the results of the present study cannot be compared with other studies.[18]

Although numerous tools are available to assess pain severity among adolescents, the visual analog scale (VAS) being more user-friendly and with easy instructions to understand was used in the present study. The patient generally reports on 3rd postsurgical day to orthodontic clinic, orthodontic appliance was placed on 3rd week and major tooth movements were initiated by 3rd month postsurgically. Hence, the time period to record the pain perception was followed after 03 days, 03 weeks, and 03 months of surgical procedure. In the present study, pain perception at 3 days postoperatively was moderate to severe in the majority of cases (P < 0.001 for all), with moderate swelling and discomfort. There was improved pain perception at 3-week postsurgery in all cases supporting that the procedure being well tolerated by patients. Although the investigator could not find any study in the literature using VAS for the assessment of pain following SFOA, hence the results of the study cannot be compared.

Limitations

Being a pilot study, the sample size was small, a larger sample size with a multicentric study would have greater clinical significance; generalizability of the findings of the current study might not be representative to an entire population. The current study did not evaluate gender-related possible differences in outcome. In measuring pain intensity, the VAS scale was used, providing a subjective assessment of the pain, the reliability of this scale is low owing to the patients' need to recall their initial pain severity before giving an estimate of their pain relief.


  Conclusion Top


With the results of the study, it can be concluded that with SFOA, there is an immediate and marked improvement in the skeletal component of the malocclusion along with significant improved in facial esthetics and dental esthetics. Hence, it confirms that there are definitive advantages of an SFOA approach, however, one has to be very careful regarding patient selection and customizing treatment plans. Hence, the SFOA approach may present a reasonable alternate for a large population requiring surgical management of skeletal malocclusion. However, bidirectional feedback among the orthosurgical team with a proper patient selection and appropriate treatment planning is required to achieve the desired results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Proffit WR, White RP, Sarver DM. Combining surgery and orthognathics: Who does what, when? In: Proffit WR, White RP, and Sarver DM, editors. Contemporary Treatment of Dentofacial Deformity. 1st ed. St. Louis, Missouri: Mosby; 2003. p. 245-67.  Back to cited text no. 1
    
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Dowling PA, Espeland L, Krogstad O, Stenvik A, Kelly A. Duration of orthodontic treatment involving orthognathic surgery. Int J Adult Orthodon Orthognath Surg 1999;14:146-52.  Back to cited text no. 2
    
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Luther F, Morris DO, Hart C. Orthodontic preparation for orthognathic surgery: How long does it take and why? A retrospective study. Br J Oral Maxillofac Surg 2003;41:401-6.  Back to cited text no. 3
    
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Hong KG, Lee JG. 2-phase treatment without preoperative orthodontics in skeletal Class III malocclusion. J Korean Assoc Oral Maxillofac Surg 1999;25:48-53.  Back to cited text no. 4
    
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Baek SH, Ahn HW, Kwon YH, Choi JY. Surgery-first approach in skeletal class III malocclusion treated with 2-jaw surgery: Evaluation of surgical movement and postoperative orthodontic treatment. J Craniofac Surg 2010;21:332-8.  Back to cited text no. 6
    
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Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: Orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg 2011;69:771-80.  Back to cited text no. 7
    
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Pilon JJ, Kuijpers-Jagtman AM, Maltha JC. Magnitude of orthodontic forces and rate of bodily tooth movement. An experimental study. Am J Orthod Dentofacial Orthop 1996;110:16-23.  Back to cited text no. 8
    
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Sirintawat N, Sawang K, Chaiyasamut T, Wongsirichat N. Pain measurement inoral and maxillofacial surgery. J Dent Anesth Pain Med 2018;17:253-63.  Back to cited text no. 9
    
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Aziz SR. Simon P. Hullihen and the origin of orthognathic surgery. J Oral Maxillofac Surg 2004;62:1303-7.  Back to cited text no. 10
    
11.
Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genpplasty: Part I. Surgical procedure to correct mandibular prognathism and reshaping of the chin. Oral Surg Oral Med Oral Pathol 1957;10:73-4.  Back to cited text no. 11
    
12.
O'Brien K, Wright J, Conboy F, Appelbe P, Bearn D, Caldwell S, et al. Prospective, multi-center study of the effectiveness of orthodontic/orthognathic surgery care in the United Kingdom. Am J Orthod Dentofacial Orthop 2009;135:709-14.  Back to cited text no. 12
    
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Brachvogel P, Berten JL, Hausamen JE. Surgery before orthodontic treatment: A concept for timing the combined therapy of skeletal dysgnathias. Dtsch Zahn Mund Kieferheilkd Zentralbl 1991;79:557-63.  Back to cited text no. 13
    
14.
Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: Two case reports of decrowding. Int J Periodontics Restorative Dent 2001;21:9-19.  Back to cited text no. 14
    
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Hsu S, Singhal D, Xia J, Gateno J, Lin CH, Huang CS, et al. Planning the surgery first approach in surgical orthodontic treatment with a computer aided surgical simulation (CASS) planning protocol. J Taiwan Assoc Orthod 2012;24:24-37.  Back to cited text no. 15
    
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Pinskaya YB, Hsieh TJ, Roberts WE, Hartsfield JK. Comprehensive clinical evaluation as an outcome assessment for a graduate orthodontics program. Am J Orthod Dentofacial Orthop 2004;126:533-43.  Back to cited text no. 16
    
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Deguchi T, Honjo T, Fukunaga T, Miyawaki S, Roberts WE, Takano-Yamamoto T. Clinical assessment of orthodontic outcomes with the peer assessment rating, discrepancy index, objective grading system, and comprehensive clinical assessment. Am J Orthod Dentofacial Orthop 2005;127:434-43.  Back to cited text no. 17
    
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Hsieh TJ, Pinskaya Y, Roberts WE. Assessment of orthodontic treatment outcomes: Early treatment versus late treatment. Angle Orthod 2005;75:162-70.  Back to cited text no. 18
    


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    Tables

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