Surgery-first approach vs conventional orthodontic surgical treatment of dental and skeletal malocclusions

Aim: The aim of this study is to assess the benefits, limits and indications of surgery first approach (SFA) and compare main features of convectional combined approach. Methods: Conventional combined surgical and orthodontic treatment of dentofacial deformity includes a prolonged period of presurgical orthodontic therapy (12-18 months) and often excessively long postsurgical orthodontic period resulting in an extended treatment time (2–3 years) which may be exhaustive for the patient to sustain. In addition, the visual impact of unpleasant fixed appliances and often worsening or aggravation of the existing deformity at dental and soft-tissue level during the pretreatment period, resulting from decompensatory tooth movements may lead to considerable patient dissatisfaction and may lead the patient to give up treatment. The surgery-first approach has been introduced to compensate the previously mentioned untoward effects of conventional orthognathic surgery (prolonged treatment period, unsightly long-term braces visibility, worsened facial deformity) yet, produce equally excellent results if carefully selected and appropriately managed. Results: Following orthognathic surgery, a period of rapid metabolic activity within tissues is known as the regional acceleratory phenomenon (RAP). By performing surgery first, RAP can be exploited to facilitate efficient orthodontic treatment. This phenomenon is believed to be a key factor in the notable reduction in treatment duration using SFA. The phenomenon of regional acceleration could be utilized to enhance faster tooth movement which considerably reduces treatment duration and may also present difficulties associated with tooth movement. It is very important that the orthodontist and surgeon involved in SFA should closely not only follow the orthognathic surgery principles but also understand the limitations of orthodontic teeth movement and the surgery-first approach. Conclusion: The surgery-first approach has improved rapidly since its introduction. The indication for the surgery-first approach has widened with technical advancement. However, the limitations of this approach should be considered. Team approach between surgeons and orthodontists is a vital component for successful treatment. The surgery-first approach was developed to improve patient care. The first indication for the surgery-first approach should be patient demand. Patients, generally, do not like preoperative orthodontic treatment. The primary aim of preoperative orthodontics is decompensation and occlusal stability after surgery. The surgery-first approach is basically a team approach between orthodontists and surgeons. Any surgery without a preoperative consultation between surgeons and orthodontists is inadvisable. Based on this consultation, the patients who do not require extensive preoperative orthodontics are indicated for the surgery-first approach. The indications for the surgery-first patient are minimal crowding in the anterior teeth, favorable curve of Spee, and normal range of angle between the basal bone to upper and lower incisors.