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.
|PI||0.66 (0.53-0.78)||0.98 (0.77-1.18)||0.04|
|GI||0.22 (0.13-0.30)||0.59 (0.35-0.8)||0.016|
They found the following significant differences for both questionnaires within the groups:
- A significant increase in quality of life between the start and one month post-op for both groups.
- Decrease in quality of life between the start and one month pre-op for the conventionally treated group.
Their overall conclusions were;
- The facial improvements after surgery led to better quality of life
- 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.
Emeritus Professor of Orthodontics, University of Manchester, UK.