**2. The advantages of SFA**

The advantages of SFA reported in literature continue. One of the advantages of the SFA is the shorter total treatment time [13, 15, 30]. Other advantages are that patients begin treatment with a much improved face esthetically in the beginning of the treatment and that the patient's chief complaint, dental function, and facial esthetics are achieved and improved in the beginning of the treatment [31, 32] and a psychosocial benefit of improved body image in the beginning of the treatment instead of worsening the facial appearance because of the presurgical decompensation of incisors [31, 34]. Improved corporation of the patient during the treatment may be the other advantage of SFA due to rapid profile improvement [33, 35]. SFA is also preferred in early correction of obstructive sleep apnea patients. On the other side, due to the early correction of skeletal and soft tissue problems, orthodontic treatment may be easier due to normalized surrounding soft tissue [23]. It was reported that the patients with preexisting TMJ dysfunction might experience a significant improvement of TMD signs and symptoms after SFA [29].

One of the reasons for the shorter duration of treatment in SFA is the regional accelerated phenomenon (RAP) which is the increase of the osteoclastic and metabolic activities due to the surgery. Selective bone injury activates stimulus for anabolic and catabolic responses in the periodontium adjacent to the osteotomies performed during orthognathic surgery and increases bone reorganization [32, 36–45]. It was reported that RAP in humans began in a few days after surgery and peaked at 1–2 months and took 6 months to more than 24 months to subside [39]. Liou et al. also studied the causes of rapid postoperative orthodontic treatment time in SFA cases, and they found that the levels of serum alkaline phosphatase and C-terminal telopeptide of type I collagen (ICTP) increased, which supported the postoperative accelerated orthodontic tooth movement caused the orthognathic surgery [15]. Zingler et al. found that crevicular fluids in SFA cases were higher levels of bone remodeling factors for fracture healing [32].

In conventional orthognathic surgery approach, the surgery follows the orthodontic treatment (orthodontic-first approach). Teeth are tended to compensate for skeletal discrepancies to have functional occlusion. The presurgical orthodontic treatment is needed to solve the dental decompensation that reveals the true extent of the skeletal deformity to align the teeth and to fit the maxilla and mandible into a good occlusion after surgery [11, 12]. Following the orthodontic treatment, orthognathic surgery corrects the skeletal discrepancy to obtain a good jaw alignment with good facial proportions. As the direction of presurgical orthodontic treatment is opposite to that of natural dental compensation forces, the orthodontic treatment time is said to require time to overcome the natural compensation forces [13]. The presurgical orthodontic treatment period which includes aligning dental occlusion, reversing incisor decompensation, correcting tooth rotation, and arch coordination lasts for 12–36 months depending on the complexity of case and also for a period after

In last 10 years, surgery first approach (SFA) has begun to be implemented in some centers

The surgery first approach (SFA) is the orthognathic surgery approach that the orthognathic surgery precedes the orthodontic treatment. In the beginning of the treatment, surgery is performed without orthodontic preparation, and the orthodontic treatment is done after the

Historically, the SFA was presented by some researchers in earlier years [2, 21–24], but SFA in a combined treatment, which was introduced officially by Brachvogel et al. [25] and by

Among the published studies about SFA regarding the type of malocclusion, Class III is the most prevalent. Class III with openbite and asymmetry cases with SFA are the other published studies. SFA in Class II cases and in some deformities like TMJ disorders or condylar

The advantages of SFA reported in literature continue. One of the advantages of the SFA is the shorter total treatment time [13, 15, 30]. Other advantages are that patients begin treatment with a much improved face esthetically in the beginning of the treatment and that the patient's chief complaint, dental function, and facial esthetics are achieved and improved in the beginning of the treatment [31, 32] and a psychosocial benefit of improved body image in the beginning of the treatment instead of worsening the facial appearance because of the presurgical decompensation of incisors [31, 34]. Improved corporation of the patient during the treatment may be the other advantage of SFA due to rapid profile improvement [33, 35]. SFA is also preferred in early correction of obstructive sleep apnea patients. On the other side, due to the early correction of skeletal and soft tissue problems, orthodontic treatment may be easier due to normalized surrounding soft tissue [23]. It was reported that the patients with preexisting TMJ dysfunction might experience a significant improvement of TMD signs and

the surgery [13].

146 Current Approaches in Orthodontics

surgery.

hyperplasia is rare [27–29].

symptoms after SFA [29].

**2. The advantages of SFA**

[14] and created broader interest [15–20].

Nagasaka et al., has gained attention in the past 10 years [26].

The other reason for the shorter duration of treatment in SFA than in the conventional approach may be improvement of function. Choi and Bradley reported that teeth tended

Figure 1. a-d: Facial asymmetry case. Passive arch wires were inserted the day before surgery.

to move in the direction of decompensation to perform the function following the surgery [46]. Postoperative orthodontic direction and function improve the efficiency of decompensation. Additionally, orthodontic movement via a more rapid natural dental adaptation by facilitating natural compensation may be performed easier with less occluded occlusion.

Orthodontic treatment time depends on the complexity of case. The shortest reported treatment time is 4 months (**Figure 1a-d**, **2a**-**d**) but generally it takes 6–12 months [17, 26, 28, 33, 35, 47–50]. Tooth extraction is the factor that influences the total treatment time [13], and in some cases, the time range was reported between 10 and 19 months [51–53].

**3. Treatment plan in SFA**

preferred [54].

pared with the conventional approaches.

lometric setup may be required before the surgery [13, 51].

Class II in cases of maxillary first premolar extraction [16].

to obtain good facial proportions, smile esthetics, and occlusion.

SFA is indicated more common in some cases like well-aligned to mildly crowded anterior teeth, flat to mildly curve of Spee, and normal to mildly proclined/retroclined incisor inclination. The protocol of presurgical orthodontics is well known in conventional approach [4, 8]; however, treatment plan including orthodontic treatment is questioned in SFA especially in complex cases. The orthodontic management and treatment plan are different in SFA com-

Surgery First Approach

149

http://dx.doi.org/10.5772/intechopen.80951

In treatment plan, accurate and detailed prediction of the postoperative orthodontic treatment is required at the beginning of all treatment [50]. Following the analysis of occlusion with model mounting, of detailed clinical and cephalometrics, presurgical orthodontic setup that is useful for accurate prediction and simulation of postsurgical orthodontics and cepha-

The model surgery is a setup according to the cephalometric and molar relationship. Three stable occlusion points between the upper and lower dentitions are required [38]. Liou et al. reported that the molar relationship could be set up in Class I in cases of nonextraction or bimaxillary first premolar extraction, Class III in cases of lower first premolar extraction, and

Following cephalometric, model, and clinical diagnosis, the aim is to optimize the position of facial components to attain the most desirable results in esthetics, function, and stability. The skeletal movements in all anteroposterior, vertical, and transverse directions are determined

Liou et al. have made some suggestions in treatment plan of SFA [16]. In Class III cases, to correct the decompensation of maxillary incisor, first premolar extraction and retraction of anterior teeth can be done by orthodontics or by anterior segmental osteotomy. If the case has moderately retroclined and crowded lower incisors, the molars in a Class I relationship with an excessive incisor overjet can be planned. In cases with severe crowding and retroclination in mandible, first premolar extraction and lower anterior setback osteotomy can be planned. In Class III cases with deep curve of Spee, leveling of Spee can be corrected before the surgery or can be corrected with lower anterior segmental osteotomy surgically to avoid upwardforward rotation of mandible postoperatively, which is not preferred in Class III cases. The chin cap therapy may be used to prevent the skeletal postsurgical relapse after surgery for 3 months [16]. In Class II cases, in mandibular retrognathia with deep curve of Spee, mandibular advancement with surgical intrusion of anterior segment to advance mandible properly or mandibular advancement followed by orthodontically intrusion of lower incisor postsurgically is proposed to obtain a better chin profile. Otherwise, the mandible cannot be advanced properly and lower face can be longer with correction of posterior openbite after surgery, and this cannot be preferred in some long face case. But in some cases where advancements are not required much, correction of posterior openbite only with posterior extrusion can be

Figure 2. a-d: Three months later after surgery. Total treatment time 3 and half months.
