Orthognathic surgery for the Invisalign

patient
Daniel I. Taub, DDS, MD, and Victoria Palermo, DDS, MD

Orthognathic surgery has continued to evolve, with increasing utilization of

digital imaging and software to facilitate both the pre-surgical orthodontics
via Invisalign therapy, as well as virtual surgical planning (VSP). While
offering the advantage of comprehensive and patient-specific analysis, these
novel technologies have also inadvertently introduced challenges in execu-
tion of the surgical plan, causing select providers to question their utility in
surgical cases. Through elimination of traditional orthodontic appliances,
which have historically served to provide anchoring hardware for intra-
operative splint stabilization, patients managed pre-surgically with Invisalign
necessitate modification of the operative techniques. Here we provide an
overview of several alternative methods to facilitate maxillomandibular
repositioning and stabilization, including utilization of Erich arch bars, Ivy
loops, intermaxillary fixation (IMF) screws and hybrid arch bar systems.
Application of these techniques in orthognathic surgery, expanded and adapted
from arena of maxillofacial trauma, allows optimization of scope of indications
for the Invisalign system and may increase case acceptance for surgical patients
seeking esthetic and minimally invasive orthodontic options. (Semin Orthod
2017; 23:99–102.) & 2017 Elsevier Inc. All rights reserved.

T reatment of malocclusion secondary to

skeletal discrepancy should include surgical
correction. Orthognathic surgical correction of
the maxillofacial complex is technique sensitive
and requires meticulous planning. There are a
limited number of fundamental surgical techni-
ques to reposition the maxillomandibular com-
plex in three dimensions. Repositioning of the
maxilla and correction of a midface projection is
usually achieved with the use of a LeFort I,II or III
osteotomy. This can be completed with or
without segmentation to achieve transverse
correction or segmental alignment. Similarly,
repositioning of the mandible is accomplished
via mandibular ramus osteotomy. Most fre-
quently, the technique of sagittal split ramus
osteotomy is used, but also when indicated, var-
iations of the technique, including vertical ramus
Department of Oral and Maxillofacial Surgery, Thomas Jefferson
University, Philadelphia, PA.
Address correspondence to Daniel I. Taub, DDS, MD, Department
of Oral and Maxillofacial Surgery, Thomas Jefferson University, 909
Walnut St, COB, 3rd Floor, Philadelphia, PA 19107.
E-mail: Daniel.Taub@jefferson.edu
& 2017 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.10.008
osteotomy, are used. As both techniques achieve
a three-dimensional repositioning of the skeletal
units, surgical splints are indispensable aids in
the process. Typically, in the process of surgical
correction of the pitch, yaw and cant of the
skeletal units, the surgeon must rely upon pre-
fabricated surgical splints. The splint is the
instrument to position the occlusion of the
opposing dental arches and it also stabilizes the
skeletal units at the new locus. While rigid
internal fixation with bone plates and screws
provides long-term stability and allows quick
return to function,1–3 the splint-aided intra-
operative intermaxillary fixation within the
occlusal splint is the mechanism that guides and
determines the position in which rigid fixation
will be accomplished.4,5
Pre-operative analysis and planning is done
based on the clinical information collected by the
surgeon. These are similar to what the ortho-
dontists collect: clinical photos, cephalometric
radiographs, dental models, bite registration,
and face bow transfer. This data, in conjunction
with ex-vivo model surgery on a semi-adjustable
articulator, allows the surgeon to assess the fea-
sibility of required surgical intervention and to
position the maxilla and/or mandible in an ideal

Seminars in Orthodontics, Vol 23, No 1, 2017: pp 99–102 99

100 Taub and Palermo
relationship.4–6 This process is a simulation of the
correction for both the occlusal deformity and
skeletal discrepancy. It is the blueprint for in-vivo
intervention. It cannot be overemphasized that
the model surgery performed on the articulator
reflects the utmost precision and accuracy of
meticulous measurements and attention to detail
to simulate surgical movements. In order to
enable the transfer of information from the
mounted dental casts to the operating field, an
interocclusal splint is fabricated by the surgeon.
It serves as the guide to position the free osteo-
tomized segment with relation to a stable skeletal
point. Furthermore, in select cases, a stabilizing
splint may be indicated in the post-operative
phase as well. It facilitates predictable bony
healing positions. For example, cases where the
maxilla or mandible have been expanded or
narrowed through a segmental approach, or
cases where stable occlusion post-operatively
cannot be achieved due to missing dentition or
severe tooth wear are critically dependent on the
splint. Secure fixation of the interocclusal splint
or stabilization of the maxillomandibular com-
plex in the anticipated interdigitated position is
key to obtaining predicted surgical outcomes.
More recently, with the advent and increased
availability of computer tomography (CT)
imaging and technology that allows sophisticated
manipulation of the generated data, virtual sur-
gical planning (VSP) and computer assisted
design/manufacturing (CAD/CAM) of surgical
splints has gained increased acceptance within
craniofacial surgery.7,8 This has been further
reinforced with increasing availability of data
supporting the accuracy of VSP,9 in addition
Figure 1. (A) Occlusal scheme established with Invisalign treatment prior to maxillomandibular advancement for
correction of skeletal discrepancy. (B) Erich arch bars in place, providing anchorage for maxillomandibular
fixation. Note preservation of gingival architecture and unobstructed access for surgical incision 5 mm apical to the
mucogingival junction.
to providing a perhaps more consistent
and comprehensive approach to treatment of
complex craniofacial disorders.10 The VSP differs
from traditional model surgery in that, it makes
use of stone models in conjunction with
maxillofacial CT data to generate a virtual
3-dimensional model combining max-
illomandibular skeletal anatomy with dentoal-
veolar form. This constructed virtual model
allows for manipulation and simulation of skel-
etal and occlusal changes and movements. The
resulting surgical plan takes into account not
only the relationship of the dental arches to each
other, but also anticipated position of the bony
segments, revealing potential challenges or
interferences. Once the virtual simulation is
completed, stereolithographic splints are fabricated
for use during surgery, theoretically eliminating
introduction of error due to multistep nature of
conventional model surgery. Despite a novel
method of surgical planning and splint fabrication,
intermaxillary fixation and stabilization of the splint
remains key in achieving predicted outcomes.
Overall, the excellence of pre-surgical ortho-
dontics is essential for the success of orthog-
nathic surgery, just as it is to post-surgical
repositioning of teeth. The orthodontist must
therefore be well versed in the surgical techni-
ques. Such knowledge makes the orthodontist
understand and appreciate the concessions that
may be necessary secondary to the use of Invis-
align therapy compared to traditional ortho-
dontics. These two orthodontic appliances are
vastly different for the surgeon who is managing
the surgery, the healing, and the long-term sta-
bility of the correction.
 Orthognathic surgery 101

Figure 2. (A) Occlusal scheme established with Invisalign treatment prior to maxillomandibular advancement for
correction of skeletal discrepancy. (B) Intermaxillary fixation screws in place providing four points of
maxillomandibular fixation, distributed bilaterally. (C) Four screws on each side provide two points of
maxillomandibular fixation, one more anterior in the canine and first premolar region and one more posterior
in the first and second molar region.

Traditional orthodontic therapy with ortho-
dontic wires provides opportunity for application of
surgical lugs or Kobayashi style ligature wires.
They are most dependable and indispensable
in their utility and facilitate intraoperative max-
illomandibular fixation into occlusion with oppos-
ing arch, as well as pre-fabricated intermediate or
final surgical splint. The Invisalign appliance has
eliminated such hardware; an additional challenge
is now created for the surgical phase. These chal-
lenges, however, can be easily circumvented with
appropriate surgical planning and application of
techniques for maxillomandibular fixation com-
monly used in the setting of facial trauma. Thus, in
the absence of lugs of Kobayashi ties, intermaxillary
fixation can be achieved by interdental wire fixation
via Ivy loops, application of Erich arch bars,11 the
use of bonded brackets or buttons, and the use of
intermaxillary fixation screws, which may be
considered under the category of temporary
skeletal anchorage devices (TADs).
Arch bars are applied to the dentition in both
the maxillary and mandibular arches and secured
by circumdental wires; with inter-arch wires sub-
sequently used to establish occlusion (Fig. 1). The
draw backs of the arch bar technique include
greatly increased operative time and consequent
patient exposure to extended anesthesia, trauma to
the periodontium, compromised oral hygiene, as
well as increased risk of penetrating trauma to the
surgeon. Interdental fixation with eyelet or Ivy
loops also relies on wires placed circumdentally,
subsequently wired together to create maxillo-
mandibular fixation. An advantage of this
technique is somewhat improved operating time
due to decreased number of circumdental wires
necessary to establish stable occlusion and
improved ease or removal following the period
of maxillomandibular fixation.
Recent development of intermaxillary fixation
(IMF) screws, starting with initial description of
their use by Arthur and Berardo in 1989,12 provided

Figure 3. Examples of commercially available bone supported arch bars. (A) SmartLock Hybrid MMF
manufactured by Stryker Craniomaxillofacial and (B) MatrixWave MMF manufactured by DePuy Synthes.
102 Taub and Palermo
an additional alternative to conventional arch bar
application. They decrease operating room time,
facilitate easier placement, and decrease the risk of
damage to the periodontal apparatus. An additional
advantage, which is of upmost importants in elective
cases, such as orthognathic surgery, is improved
acceptance by patients.13–15 Screws are positioned
in a bicortical fashion between the roots of the teeth
at the mucogingival junction or in attached tissue.
In our experience, typically eight IMF screws are
placed to provide a total of four points of max-
illomandibular fixation distributed bilaterally
(Fig. 2A and B). As all treatment modalities have
limitations and risks of distinct complications, IMF
screws are not an exception and may cause root
injury,16–18 present a risk of aspiration, screw loos-
ening, with compromise in the maxillomandibular
fixation, and screw shearing. Recent reports of
clinical studies have shown that in comparison of
self-drilling and self-tapping screws, the self-drilling
screws presented an overall better safety profile.18
Furthermore, recent development of bone
supported arch bars provides a hybrid between
circumadentally retained Erich Arch bars and
fixation screws, seeking to combine the
advantages of both. Some examples of such
appliances include the SmartLock Hybrid MMF
(Fig. 3A), manufactured by Stryker Cranio-
maxillofacial, as well as the MatrixWave MMF
System, manufactured by DePuy Synthes (Fig. 3B).
Orthodontic therapy with clear aligners has
shifted the paradigm in both the orthodontic
management of malocclusion and the intraoperative
needs of the orthognathic surgery patient during
maxillomandibular manipulation. The evolution in
software technology, specifically with manipulation
of data to create three-dimensional models, provides
multidisciplinary teams with additional opportunities
to refine treatment plans through combination of
orthodontic treatment planning and virtual surgical
planning. The concurrent elimination of conven-
tional orthodontic hardware, albeit challenging at
first glance due to compromised surface for inter-
maxillary fixation, fuels ingenuity in bringing the
concepts of maxillomandibular fixation traditionally
used in trauma into the arena of elective orthog-
nathic surgery. Here we presented alternative
options of inter-arch fixation that can be utilized
in the setting of maxillary and/or mandibular
osteotomies in the setting of Invisalign therapy; in
the process, exploring opportunities to provide
expanded scope of exceptional patient care.
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