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Roy Sabri, DDS, MS1

ORTHODONTIC OBJECTIVES IN
ORTHOGNATHIC SURGERY:
STATE OF THE ART TODAY
In treating jaw discrepancies, camouflage and surgery have different
treatment modalities, often involving opposite orthodontic mechanics
and different extraction decisions. Pretreatment identification of sur-
gical patients is therefore essential. Esthetics, function, stability, and
treatment time have to be considered and patients provided the infor-
mation they need to be part of the decision-making process. The goal
of presurgical orthodontics is to position the teeth, allowing an opti-
mal skeletal correction at surgery. While intra-arch alignment is simi-
lar to conventional orthodontics, leveling is not carried out automati-
cally in surgical patients. In open-bite cases, steps within the arches
are an indication for segmental surgery. Orthodontic leveling will be
limited to the segments, and segments will be leveled with differen-
tial intrusion at surgery. In deep-bite/short-face cases, leveling a
severe curve of Spee should be done after the occlusion is unlocked
by surgery. Anteroposteriorly, dental compensations are removed by
ideally positioning the teeth relative to their apical bases. This will
make the malocclusion look worse presurgically, but it will unravel
the true magnitude of the skeletal problem, thus allowing an optimal
correction at surgery. It is important to recognize if a transverse prob-
lem is skeletal or dental in nature and if the correction should be
done orthodontically, by segmental surgery, or by surgically assisted
palatal expansion. No orthodontic expansion should be done presur-
gically in a patient who will have surgical expansion. Any tooth
movement with relapse potential should be avoided presurgically.
Postsurgical orthodontics will bring teeth into position and proper
intercuspation within a reasonable time period. World J Orthod
2006;7:177–191.

n the or thodontic specialty, there HISTORICAL DEVELOPMENT

I seems to be a shift toward a more
adult patient population. In the 1970s,
IN ORTHOGNATHIC
SURGERY
1Clinical
only 5% of orthodontic patients were
Associate, Division of Ortho-
dontics and Dentofacial Orthope- adults; today, about 1 in 4 or 5 patients Orthognathic surgery began a century
dics, American University of Beirut fall into that category. 1 As a result, a ago with the treatment of mandibular
Medical Center, Beirut, Lebanon. larger number of patients are undergo- prognathism. 2 For almost 50 years,
ing surgical treatment. skeletal Class III patients were treated
CORRESPONDENCE by mandibular body osteotomies with an
Dr Roy Sabri
PO Box: 16-6006 external approach. Today, studies have
Beirut, Lebanon shown that isolated mandibular set-
E-mail: roysabri@dm.net.lb backs are used in fewer than 10% of the

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Sabri.qxd 5/5/06 3:42 PM Page 178
Sabri
patients, in favor of maxillary and double-
jaw surgery.3 In 1957, the introduction of
the sagittal split ramus osteotomy by
Trauner and Obwegeser 4 marked the
beginning of the modern era in orthog-
nathic surgery. This intraoral approach
allowed for both setting back or advanc-
ing the mandible with the same bone
cuts. It also provided good control of
condylar position and a broad postsurgi-
cal medullar bone interface compatible
with transoral rigid fixation.
In the 70s, Bell and Epker5 and Wol-
ford6 developed maxillary surgery, which
was pioneered earlier in Europe to treat
traumatic and gunshot wounds during
both World Wars. René LeFort noted mid-
face fractures at sites of weakness,
which logically became sites for
osteotomy cuts.7 Today, with the LeFort I
downfracture technique, the clinician can
easily advance or retract the maxilla, with
the latter being more difficult. This rela-
tive difficulty is overcome by retracting
the anterior segment only, after premolar
extraction. Clinicians can move up the
maxilla and, with autorotation of the
mandible, successfully correct skeletal
open bites and long-face syndromes. The
maxilla also can be moved down, with
less predictability. A joint mandibular
ramus surgery is advisable to allow the
mandible to move down at the chin only,
increasing the mandibular plane angle
and opening the gonial angle, rather than
rotating at the condyle, as in long-face
syndrome cases. 8 Lengthening the
ramus by moving the mandible down at
the gonial angle is unstable, even in long
faces with a short ramus, because it
stretches the muscles of mastication.
Transversely, the maxilla can be
expanded in the course of a 2- or 3-piece
LeFort technique or expanded indepen-
dently with surgically assisted rapid
palatal expansion. 9,10 The amount of
maxillary constriction is less than the
range of expansion. The mandible can
also be expanded today with distraction
osteogenesis 11 and constricted with
bone and sometimes tooth removal. Sub-
apical dentoalveolar osteotomies started
with Kole12 in the anterior mandible in
1959. Today, segmental surgery is possi-
ble in all dentoalveolar segments and
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WORLD JOURNAL OF ORTHODONTICS
improvement in instrumentation allows
for precise bony cuts, minimizing damage
to teeth and periodontal structures. It is
also possible to move the chin in all
directions to enhance the final esthetic
outcome. The 1990s witnessed the rou-
tine use of rigid fixation, which helped
increase stability, precision, patient com-
fort, and patient acceptance of surgical
treatment, mainly by eliminating inter-
maxillary fixation.
Due to the many long-term studies
available, a hierarchy of stability for the
different surgical procedures has been
established.13 It is now known that both
jaws contribute to the problem in most
dentofacial deformities.14 Setting back
the mandible only in a Class III patient
with a double jaw contribution would lead
to an increased nasolabial angle and a
short throat length; advancing the max-
illa only would also lead to compromised
facial esthetics, with biprotrusion and too
much widening of the nose (Fig 1). Dou-
ble-jaw surgery is more commonly and
easily done today. However, to get both
optimal occlusion and facial esthetics,
and avoid correcting one at the expense
of the other, presurgical orthodontic
preparation becomes crucial.
Advances in orthodontics include
bonding material; improvement in appli-
ance design, size, and esthetic appear-
ance with ceramic brackets and lingual
appliances; wire technology with fewer
appointments and better patient comfort
and skeletal anchorage. In addition, the
acceptance of orthodontic treatment by
adults has greatly improved, thanks in
part to the media showing movie stars
wearing orthodontic appliances.
TREATMENT OF JAW
DISCREPANCIES:
CAMOUFLAGE VERSUS
SURGERY
There are 2 treatment alternatives for
nongrowing patients with skeletal involve-
ment: (1) orthodontic repositioning of the
teeth to camouflage the underlying skele-
tal discrepancy; or (2) surgical reposition-
ing of the jaws at fault. Even though treat-
ment goals for the 2 treatment options
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VOLUME 7, NUMBER 2, 2006 Sabri

Fig 1 Extraoral and intraoral pho-

tographs of a Class III patient before
(a,c) and after orthodontic treatment and
double-jaw surgery (b,d).

a b

c d

are the same, namely normal occlusion,
improved facial and dental esthetics, and
long-term stability, the treatment modali-
ties are different. In camouflage treat-
ment, usually in mild to moderate jaw dis-
crepancies, conventional orthodontics will
bring maxillary and mandibular teeth
together in occlusion, while in surgical
repositioning, teeth will be positioned rel-
ative to their bony base, which means, in
many situations, farther from each other
presurgically. Extraction decisions for
camouflage will be different from, if not
opposite to, extractions for surgery. A
Class II Division 1 malocclusion treated
with mandibular advancement might
necessitate mandibular first premolar
extraction to decompensate (upright) the
mandibular incisors, allowing an optimal
surgical correction, whereas maxillary first
premolars will need to be extracted for
overjet correction if the same case were
to be treated by camouflage. The same
applies in a Class III malocclusion, where
the classical extraction pattern (maxillary
second and mandibular first premolars)
will be reversed and substituted by extrac-
tion of the maxillary first and mandibular
second premolars or no extractions in the
mandibular arch, if such a case were to
be treated surgically. It is therefore erro-
neous to start a case orthodontically and
refer the patient to the surgeon if treat-
ment is unsuccessful.
In 1985, Proffit and Ackerman15 pre-
sented the concept of 3 envelopes of dis-
crepancies: what can be corrected by
orthodontic treatment alone, through
orthodontic treatment with growth, and
through surgical treatment. These are
guidelines based on occlusal factors that
do not take into account factors such as
facial esthetics, the patient’s primary
complaint, and patient motivation. Some
authors have attempted to establish
threshold values for pretreatment identi-
fication of patients for whom surgery is
indicated.16–23 However, proper selection
of patients remains neither simple nor
straightforward. Even though long-term
studies have shown that patients’ per-
ceptions of outcome were highly positive
in both the orthodontic and the surgical
groups, no attempt should be made to
treat a patient nonsurgically because of
his apprehension toward surgery or for
reasons like avoiding the increased cost
and risk of surgery. 22 Rather, patients
should be provided the information they
need and involved in the mode-of-treat-
ment decision.21–23

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RATIONALE FOR SURGERY
There are esthetic, functional, stability,
and treatment time considerations that
will make surgery the treatment of choice
even for cases of malocclusion manage-
able by orthodontics alone.24
Esthetic considerations
Surgery should be considered whenever a
satisfactory alignment of teeth is possible
only at the expense of worsening overall
facial esthetics. For example, retracting
maxillary incisors to a retruded mandible
after maxillary first premolar extraction is
possible and will correct an overjet. How-
ever, this orthodontic approach will have
an adverse effect on the patient’s profile
because of considerable retraction of the
upper lip and an increase of the
nasolabial angle. Soft tissue limitations
should be considered and maxillary
incisors should not be retracted to the
point that the inclination of the upper lip
becomes negative to a true vertical line25
(Fig 2).
Functional considerations
A unilateral crossbite due to a functional
shift is easily manageable orthodonti-
cally, whereas surgery will be necessary
in the presence of an underlying mandi-
bular asymmetry; the more severe the
skeletal problem, the more unlikely a
nonsurgical approach can achieve nor-
mal occlusion and optimal function.
Stability considerations
Skeletal open bites and long-face syn-
dromes have been historically difficult
problems to treat before the advent of
maxillary surgery. Dental correction of an
open bite due to a posterior vertical max-
illary excess may be possible in the short
term, but will be unstable in the long
term. Furthermore, dental extrusion of
maxillary incisors in a skeletal open bite
may also create an excessive display of
gingiva, which is considered unesthetic.
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Treatment time considerations
With a combined orthognathic approach,
overall treatment time is usually shorter.
For example, in a Class II Division 1 mal-
occlusion with a prognathic maxilla,
space closure after premolar extraction
is almost spontaneous with segmental
surgery and would take 6 to 8 months
with conventional orthodontics alone.
The same applies if the Class II Division
1 is due to a retruded mandible; reducing
the overjet is much faster with mandibu-
lar advancement than with orthodontic
space closure after maxillary first premo-
lar extraction.
PRESURGICAL ORTHODONTIC
PREPARATION
The goal of presurgical orthodontics is to
position the teeth so that an optimal
skeletal correction can be performed at
surgery. Intra-arch alignment and trans-
verse discrepancies should be addressed
so that arch compatibility can be achieved
after surgery. Incisors are the surgeon’s
guide to anteroposterior jaw positioning,
and their vertical position prior to surgery
will determine postsurgical lower facial
height. In the planning process for surgi-
cal-orthodontic treatment, it is therefore
important to decide: (1) where to place
the teeth anteroposteriorly, vertically, and
transversally; and (2) how to position
these teeth or tooth segments, surgically
or orthodontically, to maximize the speed
and efficacy of treatment. No attempt
should be made to perfectly level arches
and reach an ideal intercuspation on
presurgical working casts; rather, the
orthodontist should take full advantage of
the unlocked occlusion after surgery to
more efficiently complete tooth detailing
in all dimensions.26
Intra-arch alignment
The first step in presurgical orthodontics
is to align the arches and/or arch seg-
ments and make them compatible. These
initial intra-arch objectives are the same
in combined orthognathic and conven-
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VOLUME 7, NUMBER 2, 2006 Sabri

a b c

d e f

Fig 2 Extraoral and intraoral photographs of a skeletal Class II patient before orthodontic treatment (a,d), in retention (b,e),
and 8 years postretention (c,f).

Fig 3 Intraoral photographs of presur-

gical maxillary intra-arch alignment in a
unilateral cleft lip and palate patient.

tional orthodontics. The decisions for
extraction of compromised teeth, the
recuperation of impacted teeth, the cor-
rection of rotations, crowding, arch length
discrepancies, and the overall alignment
of teeth are all carried out systematically
at this point (Fig 3). Tooth-size discrepan-
cies should also be identified and elimi-
nated. 27,28 Once accomplished, these
intra-arch objectives will allow proper den-
tal interdigitation after surgery. Whenever
segmental surgery is planned, root diver-
gence adjacent to the osteotomy cuts is
done from the initial archwire and moni-
tored with periapical radiographs. This will
avoid root trauma, gingival recession, and
possible ankylosis after surgery.27

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Leveling and vertical
incisor position
Leveling and arch alignment are usually
done systematically as a 1-step procedure
in conventional orthodontics. This routine
procedure cannot be applied to surgical
cases because arch leveling, which is
done by a combination of dental extrusion
and intrusion, will achieve different verti-
cal tooth movements in different maloc-
clusions. For example, in an anterior
open-bite/long-face case, leveling will
tend to extrude anterior teeth, while in a
deep-bite/short-face case, leveling will
tend to intrude anterior teeth because
strong musculature will fight posterior
tooth extrusion. As mentioned earlier,
incisors are the surgeon’s guide to jaw
positioning and their vertical position at
the time of surgery will determine postsur-
gical vertical lower facial height. If incisors
are intruded presurgically in the deep-
bite/short-face case, facial height will not
be increased by surger y. The same
applies for the open-bite/long-face case,
where incisor extrusion will decrease the
dental open bite before surgery but will
interfere with optimal correction of the
vertical excess at surgery. Furthermore,
the dental relapse potential built in with
systematic leveling will lead to postsurgi-
cal partial recurrence of the open bite or
deep bite. As a general rule, any tooth
movement with a relapse potential should
be avoided presurgically.28
Presurgical leveling in open-bite
cases. In planning presurgical orthodon-
tic preparation for an open-bite case, it is
important to identify which group of teeth
is at fault. In a patient with a gingival
smile that is more excessive posteriorly
than anteriorly, the presence of 2 vertical
discrepancies or steps within the maxil-
lary arch is an indication for segmental
surgery. The open bite will be corrected
by differential surgical intrusion of the
posterior and anterior segments and
closing rotation of the mandible. Thus,
orthodontic leveling will be limited to the
segments and the segments will be lev-
eled at surgery. This will allow a correc-
tion of the increased vertical facial height
at surgery and will eliminate the ten-
dency for posttreatment dental relapse
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WORLD JOURNAL OF ORTHODONTICS
(Fig 4). In the presence of a flat curve of
Spee initially, with no vertical discrepan-
cies within the arch, leveling can be done
conventionally with a continuous arch-
wire. The open bite will be corrected by a
1-piece LeFort osteotomy with more
impaction posteriorly than anteriorly (Fig
5). This posterior impaction will have an
uprighting effect on the incisors that
should be accounted for.
Presurgical leveling in deep-bite
cases. In a deep bite, the decision to
level by intrusion of incisors or extrusion
of posterior teeth depends on the initial
facial height. If the anterior lower facial
height is short and the distance between
the mandibular incisor edge and the chin
is normal, then leveling by extrusion of
posterior teeth is indicated, so that the
chin will move down at surgery.29 Presur-
gical leveling would have to overcome the
heavy biting forces often associated with
a deep bite. Rather, a curve of Spee is
left in all archwires, including the surgical
stabilizing wire. Mandibular advance-
ment surgery is going to create a lateral
open bite, with tooth contacts only on
anterior and posterior teeth. Now that the
occlusion is unlocked by surgery, extru-
sion of posterior teeth is facilitated by the
absence of tooth contacts and is done
with flat archwires and lateral box elas-
tics (Fig 6). If incisors are intruded presur-
gically in a deep-bite/low-angle case,
surgery will tend to move the mandible
upward at the chin and downward at the
gonial angle, due to the pivot effect. This
increase in posterior facial height will
elongate the muscles of mastication and
is unstable. Instead, when incisors are
not intruded presurgically in the deep-
bite/short-face patient, surgery will move
the chin down, thus introducing an open-
ing mandibular rotation, which tends to
be more stable than straightforward or
closing rotations30 (Figs 6c and 7). Con-
versely, if the anterior lower facial height
is excessive, an accentuated mandibular
curve of Spee should be leveled presurgi-
cally by intrusion of the anterior segment
or leveled surgically with a subapical
osteotomy after segmental orthodontic
leveling. A joint maxillary surgery will
often be needed to avoid downward
movement at the gonial angle.
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VOLUME 7, NUMBER 2, 2006 Sabri

a b c

d e f

g h i

Fig 4 Extraoral and intraoral photographs, tracing and visual treatment objective (VTO), and cast surgery of an open-bite
patient before (a, c to g), presurgical sectional orthodontics (h), and after 3-piece maxillary LeFort I osteotomy, sagittal split
mandibular ramus osteotomy, mandibular anterior subapical osteotomy and genioplasty (b,i).

Anteroposterior incisor position incisors are often uprighted, while the

During surgery, jaws and dentoalveolar
segments are mobilized until teeth are
brought together. Just as the vertical
presurgical position of the incisors deter-
mines postsurgical facial height, it is the
anteroposterior position of the incisors
that will determine how much the maxil-
lary and/or the mandibular jaw can be
repositioned anteroposteriorly during
surgery.29
In a severe skeletal dysplasia, teeth
try to maintain some occlusal contacts
compensating for the skeletal problem in
all 3 planes of space, particularly antero-
posteriorly. For instance, in a skeletal
Class II malocclusion, the maxillary
mandibular incisors are proclined. The
dental overjet is not indicative of the real
amount of the underlying skeletal dis-
crepancy. Likewise, Class III malocclu-
sions often tend to exhibit proclined max-
illary incisors and uprighted or lingually
inclined mandibular incisors. While these
dental compensations are maintained or
increased in orthodontic camouflage to
reach good dental interdigitation, the
opposite is done in surgical treatment.
Presurgical orthodontics will remove den-
tal compensations by positioning the
teeth ideally relative to their apical bases.
This dental “decompensation” will make
the malocclusion look worse presurgi-
cally, but will unravel the true magnitude

183
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Sabri WORLD JOURNAL OF ORTHODONTICS

a b c d

e f g

h i j

k l m

Fig 5 Extraoral photographs pretreatment (a,b); posttreatment (c,d). Intraoral pho-

tographs before (e to g), presurgical (h to j), and after 1-piece maxillary LeFort I
osteotomy with posterior impaction, sagittal split mandibular ramus osteotomy, and
genioplasty (k to m). Superimposition tracing (n).

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VOLUME 7, NUMBER 2, 2006 Sabri

a b c

d e f

Fig 6 Extraoral photographs of a Class

II deep bite-low angle patient before (a)
and after (b) treatment. Superimposition
tracings (c). Presurgical and hand-articu-
lated study casts simulating mandibular
advancement (d,e). Intraoral photograph
2 weeks postsurgery (f). Intraoral pho-
tographs before (g) and after (h) treat-
ment.
g h

Fig 7 (a) Retrognathic mandible lev-

eled presurgically (solid lines) and after
advancement (dotted lines): 1, closing
mandibular rotation; 2, increased poste-
rior facial height; 3, no increase in ante-
rior facial height. (b) Same case not lev-
eled presurgically (solid lines) after
mandibular advancement (dotted lines):
1, opening mandibular rotation; 2, no
increase in posterior facial height (more
stable situation); 3, increase in anterior
facial height.
1
1

2
2 3
3
a b

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Sabri WORLD JOURNAL OF ORTHODONTICS

a b c

d e f

Fig 8 Extraoral and intraoral pho-

tographs of a Class III patient before
treatment (a,d), presurgical (b,e), after
orthodontics and double-jaw surgery
(c,f), and superimposition tracing (g).

of the skeletal problem, allowing an opti-
mal correction at the time of surgery,
without any limitations or interferences
from the occlusion (Fig 8). Failure to fully
remove anteroposterior incisor compen-
sations presurgically will limit the surgical
correction, leading to compromised facial
esthetics and occlusion. Such anteropos-
terior dental “decompensation” may
involve specific extractions and anchor-
age needs and will often necessitate the
use of Class III elastics in Class II cases
to upright mandibular incisors and
advance maxillary molars into a full Class
II occlusion. Conversely, Class II elastics
would be used in Class III cases to pro-
cline mandibular incisors and establish
adequate reverse overjet. In the presence
of minimal attached gingiva or a thin
periodontium in the anterior mandibular
region, a gingival graft might be indicated
before any labial tooth movement to
avoid gingival stripping or dehiscence31
(Fig 9).
Anterior subapical osteotomies in con-
junction with first premolar extractions
are often indicated in severe maxillary
dentoalveolar protrusion. A setback of
the osteotomized anterior segment with
a clockwise rotation of more than 10
degrees would cause a marked vertical
step between the canines and the sec-
ond premolars in the stationar y
segment32 (Fig 10). To avoid severe steps

186
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VOLUME 7, NUMBER 2, 2006
Fig 9 Intraoral photographs of a Class
III patient before (a) and after (b) gingi-
val graft in the anterior mandibular
region, orthodontics, and mandibular
setback.
a b
Fig 10 A severe clockwise rotation of
the osteotomized anterior segment,
causing a marked step between the
canine and the second premolar.
that can be difficult to level later, a par-
tial surgical setback is done with minimal
clockwise rotation of the mobilized seg-
ment leaving 2 to 3 mm of extraction
space on each side, which will be closed
postsurgically with round wires; or proper
inclination of the incisors and canines is
established presurgically, so that exces-
sive rotation of the anterior segment at
surgery can be avoided.29,32
Arch coordination and transverse
problems
A final objective in presurgical orthodon-
tics is to get reasonable arch compatibil-
ity when jaws or dentoalveolar segments
are mobilized during surgery. Usually,
arch compatibility is achieved sponta-
neously with the normal progression of
coordinated maxillary and mandibular
continuous archwires, toward the full-
dimension rectangular wires or surgical
wires33 (see Fig 5). This will only be possi-
ble in the absence of severe transverse
problems, such as with cleft lip and
palate patients. Transverse problems are
often overlooked because posterior den-
tal compensations are less obvious than
incisor compensations for anteroposte-
rior skeletal discrepancies. The presence
or absence of a posterior crossbite is not
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Sabri
indicative of a transverse problem, partic-
ularly when it is associated with severe
anteroposterior problems.34 In a severe
skeletal Class II malocclusion, a narrow
and V-shaped maxillary arch is often
associated with a more ovoid mandibular
arch. By hand-articulating the study casts
into a Class I canine relationship, simu-
lating a mandibular advancement, a
bilateral crossbite not existing initially,
will appear because the mandibular arch
is moved forward into a more constricted
area of the maxillary arch. Presurgical
orthodontics should, therefore, include
expansion of the maxillary arch. This
transverse expansion in the absence of a
crossbite will lead to a buccal crossbite
or Brodie syndrome that will self-correct
with mandibular advancement at surgery
(Fig 11). On the other hand, a posterior
crossbite in a Class III malocclusion
might not need to be addressed presurgi-
cally because it will self-correct with a
mandibular setback, as the mandibular
arch is moved to a wider portion of the
maxillary arch at surgery or as the maxil-
lary arch is moved into a narrower area of
the mandibular arch with a maxillary
advancement.
Incomplete transverse correction will
lead to instability and unsuccessful cor-
rection of the malocclusion. It is impera-
tive to recognize a transverse problem
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a b c

d e f

Fig 11 Intraoral photographs of a skeletal Class II patient with severe overjet and V-shaped maxillary arch before treatment
(a,b), hand-articulated study casts simulating mandibular advancement leading to a bilateral crossbite (c), intraoral photograph
after expansion leading to a reverse bilateral crossbite (d), and after treatment (e,f).

from the beginning. It is also essential to PLANNING FOR SURGERY

note whether it is skeletal or dental in
nature and if the correction is going to be
done or thodontically, by segmental
surgery, or by surgically assisted palatal
expansion. 35 Orthodontic expansion
should be done only within the bound-
aries of the normal orthodontic capabil-
ity, and while up to a half-cusp crossbite
can be left for correction after surgery,
skeletal discrepancies should not be
masked by compensatory dental move-
ments.33,36 As with the vertical dimen-
sion, tooth movements with relapse
potential should be avoided before
surgery. In cases where maxillary surgery
is not considered, a constricted maxillary
arch can be corrected separately with
surgically assisted rapid maxillary expan-
sion.35 Whenever a 2- or 3-piece maxil-
lar y LeFor t osteotomy is indicated,
surgery will resolve the transverse prob-
lem and orthodontic treatment will be
limited to the segments. No orthodontic
expansion should be done presurgically
in a patient who will have surgical expan-
sion.33 Finally, arch compatibility in surgi-
cal patients cannot be checked clinically;
the only reference to whether it has been
achieved lies in the articulation of study
casts. Once the outcome is satisfactory,
the patient is ready for surgery.
The orthodontist should take progress
casts as the patient approaches the end
of orthodontic preparation for surgery.
Impressions should be taken with the
archwires removed to avoid distortion.
After the needed final orthodontic adjust-
ments have been made, full-size stabiliz-
ing archwires should be placed and kept
for 3 to 4 weeks to become passive
before presurgical records are taken.
These records include panoramic and lat-
eral cephalometric radiographs, study
casts, and facial and intraoral pho-
tographs. A posteroanterior cephalomet-
ric radiograph is also needed in cases of
asymmetry and transverse problems.
All diagnostic and prediction proce-
dures done initially should now be
repeated, with the presurgical records for
the final surgical planning. In cases involv-
ing maxillary surgery, cephalometric pre-
dictions will simulate surgical move-
ments, quantify the autorotation of the
mandible, and evaluate the resulting soft
tissue profile. Cast surgery is done next
and has 2 objectives: (1) to duplicate sur-
gical movements from the prediction trac-
ings and confirm their feasibility for the
occlusion; and (2) to fabricate the surgical
interocclusal wafer splints to be used dur-

188
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Sabri.qxd 5/5/06 3:43 PM Page 189
VOLUME 7, NUMBER 2, 2006
ing surgery.33,37 A semi-adjustable articu-
lator with a facebow transfer is used
whenever a LeFort I osteotomy is planned
without mandibular ramus surgery. In
such a situation, where the condyle-denti-
tion relationship is preserved during
surgery, it is important that the autorota-
tion of the mandible to a new position be
simulated as accurately as possible.33
Conversely, if the condyles are to be sepa-
rated from the dentition by a vertical
ramus osteotomy, there is no need to
maintain this relationship during cast
surgery. Therefore, an arbitrary articulator
can be used in cases of mandibular
ramus surgery without maxillary surgery.
In double-jaw surgery, the mandibular
position with the condyles intact will be
the guide for repositioning the maxilla
before mandibular surgery is performed;
therefore, an articulator mounting is
required. 33 The maxillary cast will be
mobilized first and stabilized on the artic-
ulator. A first occlusal splint is made for
this position.38,39 The mandibular cast is
then mobilized, brought into occlusion
with the maxillary cast, and stabilized. A
second splint is constructed in this final
position. It is important that this final
splint be thin, as a thick splint will
increase the possibility of error as the
mandible rotates into occlusion when the
splint is removed. A wire embedded in the
lingual acrylic can be used as reinforce-
ment. The splint should not cover the buc-
cal surface of the teeth; this allows visual
verification of proper seating at surgery.29
If the surgeon can bring the casts
together and easily reproduce the occlu-
sion, a splint is not really necessary. How-
ever, in segmental surgery, it ensures
accurate performance of the surgical
movements and also eliminates the need
for the orthodontist to be present during
surgery to place a continuous archwire to
lock the osteotomized segments.
It is imperative that the final presurgi-
cal wires be completely passive. This will
ensure that there will be no dental
changes between the time of the impres-
sion and the surgery, which could lead to
a poorly fitting splint and errors in the
planned surgical moves.27 Some type of
attachments may be placed on the arch-
wires or the brackets to facilitate fixation
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before screws and plates placement. Sol-
dered brass spurs in each interproximal
area are the preferred mode of attach-
ment, if care is taken not to overheat the
wire. Preformed crimp-on hooks can also
be placed with special pliers directly over
the wire without removing it. This is much
easier and faster than soldered spurs.
However, these types of hooks are not
tight and can slip along the wire during
surgery. While crimping, care should be
taken to avoid any archwire distortion
that might not be noticed if the wire is
not removed and will result in a poorly fit-
ting splint at surgery.33
SURGICAL MANAGEMENT
AND POSTSURGICAL
ORTHODONTICS
With rigid fixation techniques, the acrylic
splint is ligated to one of the arches at
surgery to key the occlusion, and light
elastics are used to guide jaw function. A
soft diet (ie, milkshakes, yogurt, mashed
potatoes) is advised for the first week fol-
lowing surger y. Patients can then
advance their diet progressively, deter-
mined by comfort level. By 6 to 8 weeks,
the jaws should be healed enough for
heavy mastication. Healing may not nec-
essarily be faster with rigid fixation, but
bony segments are more stable right
after surgery, allowing limited early func-
tion. This can be assisted by physical
therapy, in which patients are advised to
gently open and close their mouths
within comfortable limits starting 1 week
af ter surger y. These exercises are
increased over the next 2 weeks to 3 10-
to 15-minute sessions of opening and
closing, as well as lateral movements.29
Patients are usually back to work within 1
week or 10 days after surgery, and most
facial edema is gone 2 to 3 weeks post-
surgery. It is possible to resume postsur-
gical orthodontics as early as 2 weeks
following surgery with rigid fixation, while
6 to 8 weeks are required with wire
osteosynthesis and maxillomandibular
fixation.
The goal of postsurgical orthodontic
treatment is to bring the teeth to well-
detailed positions and proper intercuspa-
189
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tion within a reasonable time (4 to 6
months), taking advantage of the unlocked
occlusion following surgery. At the first
postsurgical orthodontic appointment, the
splint is removed and the stabilizing arch-
wires are replaced with continuous work-
ing archwires. A long appointment should
be scheduled to allow for repairs, because
loose bands or brackets are not uncom-
mon after surgery. It is important that
when the splint is removed, the stabilizing
archwires be removed at the same time.
After splint removal, dental intercuspation
might not be perfect, with only 2 or 3 teeth
in contact; if the stabilizing archwires that
hold the teeth rigidly are left in place, a
shift to an undesirable convenience bite
with greater intercuspation will result.33
This will complicate orthodontic finishing
and could stress osteotomy sites. Rather,
teeth should be allowed to settle rapidly to
full contact right after splint removal and
this is best done on light, undersized
round wires, typically 0.016-inch stainless
steel assisted by light box elastics. These
elastics are not necessarily vertical, but
could have an anterior or a posterior vector
to support the sagittal correction. They
should be worn full-time, including during
meals, for the first 4 weeks. This phase
should not last more than 6 to 8 weeks.
Weekly visits are recommended for better
control, allowing the orthodontist to
change box elastics into a Class II or Class
III direction as needed. If tooth movement
is desired on the mandibular arch only, to
level a severe curve of Spee, the maxillary
stabilizing archwire can be maintained and
a mandibular flexible wire can be placed.
In segmental surgery, elastics should not
be used on sectional archwires because
they rapidly distort arch form. A continuous
archwire should replace sectioned arches
after splint removal. Whenever palatal
expansion has been performed during
surgery, postsurgical flexible archwires
needed for tooth settling cannot prevent
transverse relapse. A transpalatal bar or a
heavy labial wire (0.036-inch) placed in the
headgear tubes can be used for trans-
verse control. If root divergence was per-
formed presurgically, root parallelism
should be achieved. By this time, postsur-
gical orthodontic finishing is much the
same as with conventional orthodontics;
190
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WORLD JOURNAL OF ORTHODONTICS
there is also nothing specific about reten-
tion in surgical patients. The retention
appliance is placed depending on the ini-
tial malocclusion.
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