August 07, 2017

A trial on “surgery first” orthognathic surgery.

One of the most interesting recent orthodontic developments is the “surgery first” approach for orthognathic  surgery. This post is about a new trial that provides us with some information on this technique.

This type of treatment is relatively new and appears to be gaining in popularity. In “surgery first” orthognathic treatment, surgery is provided soon after orthodontic appliance placement. As a result, patients do not need  extensive pre-surgical orthodontics. Currently, the evidence underpinning this form of treatment is at the early stage of case report and case series. I was, therefore, very interested to see this trial that the American Journal of Orthodontics has published. A team based in Rome and Milan, Italy, did this study.

Surgery-first orthognathic approach vs traditional orthognathic approach: Oral health-related quality of life assessed with 2 questionnaires

Sandro Pelo et al. Am J Orthod Dentofacial Orthop 2017;152:250-4)

The authors wrote a good clear introduction outlining the underpinning philosophy of this treatment. They stated that one of the problems of the conventional “orthodontics first” approach is that patients have high levels of anxiety and low satisfaction with body image during the first phase of treatment. This may be caused by the decompensation phase of orthodontic treatment making facial profile worse. They also mentioned that another negative factor is uncertainty about the operation date.

They then stated that the advantages of the “surgery first” approach are;

  • Eliminating or reducing pre-surgical orthodontic treatment
  • Immediate placement of the jaws in the desired positions
  •  A short post-surgery orthodontic phase

Unfortunately, they did not provide a reference for these statements.

What did they ask?

They wanted to answer this question;

“Are there any differences in patient-related outcomes between the conventional surgical approach and the surgery first approach”?

What did they do?

They did an RCT with the following PICO.

Participants: Orthognathic surgery patients with mild to no dental crowding and a mild curve of speed who required bimaxillary surgery.

Intervention: Surgery first orthodontics

Control: Conventional surgery with pre-surgical orthodontic treatment.

Outcome: Orthognathic Quality-of-Life questionnaire and Oral Health Impact Profile.

They gave questionnaires to the patients at the following time points:

To Before bracket placement

T1 One month pre-op

T2 One month post-op

They provided conventional pre-surgical orthodontic treatment to the patients in the control group. The mean duration of this phase was 20.6 +/- 1.9 months.

They put brackets on the surgery first group 3 days before their operations.

What did they find?

All 30 participants completed the study.  I have extracted the relevant data from the questionnaires and put it in these tables. I also calculated the 95% Confidence Intervals.

AppOHI onlyP
PI0.66 (0.53-0.78)0.98 (0.77-1.18)0.04
GI0.22 (0.13-0.30)0.59 (0.35-0.8)0.016

They found the following significant differences for both questionnaires within the groups:

  1. A significant increase in quality of life between the start and one month post-op for both groups.
  2. Decrease in quality of life between the start and one month pre-op for the conventionally treated group.

Their overall conclusions were;

  1. The facial improvements after surgery led to better quality of life
  2. There is a reduction in quality of life during pre-surgical orthodontic treatment.
What did I think?

To be honest I’m not sure about this paper.

I cannot help thinking that the authors analysed and published their results to soon. We need to remember that this data was collected only one month after surgery.  I think that we need to see information on cephalometric/facial change, occlusal changes and patient outcomes at the end of treatment. For example, we do not know if the quality of life of the “surgery first” patients deteriorated during the post orthodontic treatment phase.

I’m also not sure if the changes that they reported in the quality of life measures are clinically important. This is essential information that we need to interpret the findings of this study.

I was also rather concerned to see that there was no information on ethical committee approval. In addition, there were no details of randomisation, concealment and blinding. This is a major problem and puts the study at high risk of bias.

Unfortunately, my overriding feeling about this paper is disappointment. Nevertheless, I think that it may provide us with interesting initial data but we need to be careful in our interpretation.

I hope that the authors extend their study to the completion of all treatment. A paper based on this data would be a really useful contribution.  At present, we do not have much useful information on this very interesting technique which may have great potential benefit to our patients.

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Have your say!

  1. The reference points for planning surgery first are still not clearly stated. Which cephalometric/ facial points have defined the predicted final ANB, for example? Is it a Dolphin generated prediction? I’d also like more answers.

  2. Kevin. I am not surprised by their limited findings. The OMFS that I work with and I began using a surgery first approach about five years ago, at first specifically with patients who had severe obstructive sleep apnea. I have always placed the brackets the day before surgery but it would seem three days would be fine provided the surgical stents still fit properly. Our goal at the time was immediate relief for the patient from their CPAP machine which thus far has been universal, although we warn them there remains a possibility of continued necessity post surgery.

    The planning is typically done virtually through a third party software with orthodontist and surgeon coming to an agreement on final bone positioning, partially based on where the teeth are most likely to end up given a “class I” skeletal base (in other words few if any elastics, etc.). That means the orthodontist must plan for post treatment decompensation and understand their own capabilities well. Many times the occlusal contact post surgery is very limited at first and requires very close supervision and sometimes occlusal buildups to provide stability that are then gradually removed.

    My point to is all this is that although it may be easier on the patient, and is my preferred approach when it best suits the needs of the patient, a surgery first approach requires far more detailed planning and teamwork by the orthodontist and surgeon and I believe should be approached with a health dose of caution and humility when initially attempting this technique. Because all patients are not good candidates a true Blinded RCT that also evaluated occlusal relationships and other comparable findings would likely need fairly rigorous exclusion criteria.

  3. Dear Professor O’Brien
    Thank you, It was great, There is a lot of points that should be clear before assessing the quality of life of “surgery first” patients. As you mentioned, post surgical QOL, final appearance of the face and the final occlusion.
    Are we allowed to make surgery first just to increase QOL, or we have to put good treatment results first?”

  4. Dear Dr. O’Brien

    Thank you for your interest in our paper.
    We agree with you about the fact that our results are absolutely preliminary and that further studies should be carried out in order to better define this matter.
    We are grateful for your suggestions that will help us to implement our studies, following better scientific criteria.
    This is only a preliminar study and It should only be considered as a starting point.
    As you also said, little was reported about this technique and we still need time to gather definitive data.
    We were pushed to study this aspect of the therapy ( degree of patients’ satisfaction ) by our clinical practice.
    In fact during follow up time we have noticed a high level of enthusiasm and satisfaction were, among patients treated with surgery first approach, compared to the discomfort and distress reported by patients treated with the traditional orthodontic-first approach that involves a long decompensative pre-surgical orthodontic treatment.
    Given that we all agree that the traditional approach is able to provide very good results, Surgery First is just a matter of “standing on patient’s side”.

  5. Kevin,

    I have not been as aggressive as the authors in a surgical first approach. However, I have had a couple case studies in which there was difficulty in getting leveling of the arch pre-surgical. I am fortunate to have a great collaboration with my surgeon and he performed surgery to give me a three point contact. Both cases I was able to align immediately post surgical. I think as in most cases the compromise will be the gold standard. Maybe the future will be a surgical procedure after alignment. This will allow for many of the “positive” findings from Sandro Pelo et al. and possibly lead to easier finishing by establishing proper skeletal alignment to help alleviate interferences. This may give us the ability to be “close enough” to give a better prediction for outcomes, and at the same time allow for more efficient treatment. I agree Kevin, that this is an interesting step that will lead to more research.

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