齒顎矯正協會-TJO

*
Review Article

Surgical Occlusion Setup in Orthognathic Surgery Using Surgery-first Approach for Skeletal Class III Deformity: A Systematic Review

Shu Hsien Lo, DDS1,2, Yu-Fang Liao, DDS, PhD2-4
1Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Linkou, Taiwan
2College of Medicine, Chang Gung University, Taoyuan, Taiwan
3Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
4Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan

 
Objective: Surgery-first orthognathic surgery is increasing in popularity because of reduced treatment time, efficient tooth decompensation, and early improvement in facial esthetics. However, it remains difficult due to the surgical occlusion setup. We systematically reviewed the literature in order to determine the guidelines used for surgical occlusion setup in orthognathic-first surgery for skeletal Class III deformity.

Material and Methods: The literature was searched using PubMed, Medline (Ovid), Cochrane Library, Web of Science and Google Scholar databases from January 1931 to June 2017. We limited the search to publications in English. Two independent investigators used specific inclusion and exclusion criteria to extract and analyze the data. Study quality was assessed objectively.

Results: Of 288 papers retrieved, 13 met the inclusion and exclusion criteria. All studies were of low quality. The occlusion was suggested to be set as Class I, II or III molar relationship, deep bite or posterior open bite, little or no posterior crossbite or no complete posterior dental or skeletal crossbite, and stable posterior occlusion or at least three occlusal stops.

Conclusions: The results should be interpreted with caution due to the low number, poor quality, and heterogeneity of the included studies. Due to contradictory results and poor study quality, the scientific evidence is too weak to show the guidelines of surgical occlusion setup in surgery-first orthognathic surgery for skeletal Class III deformity. Further quantitative studies are required.

Keywords: orthognathic surgery, skeletal Class III, surgery-first approach, surgical occlusion
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Introduction

Before the 1960s, most orthognathic surgeries were performed either without orthodontic treatment or before any orthodontic treatment. As the stability of the results improved and satisfaction with the post-treatment outcomes increased the three stages of classic surgical orthodontic treatment became popular.1 The 3-stage approach requires a variable length of pre-surgical orthodontic preparation to decompensate the malocclusion. Pre-surgical preparation is followed by surgical correction of the skeletal discrepancy and a relatively short period of post-surgical orthodontic treatment, which allows for detailing and finishing of the occlusion. Pre-surgical orthodontics typically includes dental alignment, incisor decompensation, arch leveling and coordination, and usually requires 15 to 24 months.2,3 However, pre-surgical orthodontics exacerbates facial esthetics and dental function, and causes patients a significant amount of discomfort prior to surgical treatment.2 One study found that one third of patients rated the orthodontic treatment as the worst part of their orthognathic treatment owing to the appliances’ visibility and discomfort, and the length of treatment.4

A new approach to orthognathic surgery is called “surgery-first,” which eliminates the pre-surgical orthodontic phase, avoiding the longer treatment time and transitional detriment to facial esthetics and dental function associated with pre-surgical orthodontic treatment.5-7 Surgery-first orthognathic surgery is increasing in popularity because of several advantages: reduced treatment time, efficient tooth decompensation, and early improvement in facial esthetics, especially in Class III malocclusion.5-10 These advantages positively influence a patients’ global satisfaction with treatment. The optimal esthetic and functional results, significant reduction in total treatment time, and high patient satisfaction have led to the postulation that the surgery-first approach may represent a reasonable and cost-effective method to manage skeletal deformity, and has the potential to become a standard approach of orthognathic surgery in the future.5,8
However, the most difficult step for the surgery-first approach is the setup of the transitional occlusion at the time of surgery (i.e., surgical occlusion). Because dental alignment, arch leveling and coordination, and incisor decompensation are deferred, a major consideration for the surgical occlusion setup with the surgery-first approach is to compensate for the space required for the dental movement. This is similar to the process that the orthodontist performs to correct any malocclusion of skeletal Class I, because skeletal deformity is corrected from the start. Accurate surgical occlusion setup is important to avoid severe postoperative occlusal instability, incomplete or excessive skeletal correction, or skeletal asymmetry. However, a systematic review of surgical occlusion setups used with the surgery-first approach has not been undertaken. The aims of this study were to conduct a systematic review of the literature on orthognathic surgery and to identify guidelines for surgical occlusion setup in patients who had undergone surgery-first orthognathic surgery for Class III malocclusion.
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Material and Methods

Eligibility criteria
The following inclusion criteria were applied for the literature review: (1) human patients; (2) patients who underwent surgery-first orthognathic surgery for correction of skeletal Class III deformity; (3) at least one guideline for surgical occlusion setup was described; and (4) the study design was case report, case series, case-control study, cohort study, or randomized controlled trial. The exclusion criteria were as follows: (1) syndromic patients; (2) congenital deformity; (3) unrelated disease (i.e., oncologic or traumatic cases); (4) experts’ opinions or suggestion; or (5) reviews.

Literature search
To identify relevant publications, we searched the following electronic databases: PubMed, Medline (Ovid), Cochrane Library, Web of Science, and Google Scholar databases from January 1931 to June 2017 using the MeSH terms “orthognathic surgery” or “jaw surgery” and “surgical occlusion” or “transitional occlusion” or “occlusion,” or “three-point contacts,” and “surgery first” or “orthognathic first” and “mandible prognathism” or “Class III malocclusion.” We limited the search to publications in English. Hand searches were undertaken to find additional relevant published material that might have been missed in the electronic searches.
A 3-stage screening (titles, abstract, and full text) was carried out independently and in duplicate by two researchers (S.H.L and Y.F.L). The title and abstract of each retrieved article were first independently screened by the two researchers for reports of surgical occlusion setup in skeletal Class III deformity. After reviewing the abstract only, we classified articles as included, excluded, or unclear. Differences about which articles to include or exclude were resolved by consensus. For articles classified as included or unclear, we then obtained the full papers. The full papers were reviewed independently by both authors, and final inclusion was based on the inclusion and exclusion criteria. Inter-researcher agreement on study selection was assessed by Cohen's kappa.

Data items and collection
Articles were independently analyzed to extract the following data: author, year of publication, country, study design, type of deformity, number of patients, type of surgery, type of orthodontic mechanism, and guideline of surgical occlusion setup.
The quality of each paper (i.e., the soundness of its methods) was also independently evaluated according to PRISMA11 and MOOSE12 statements with five criteria: random sampling, subject selection described, valid methods, confounding factors considered, and adequate statistics provided. The quality of each article was categorized as low (≤3 criteria fulfilled), moderate (4 criteria fulfilled), or high (5 criteria fulfilled). Data were extracted and the quality of each paper was assessed independently by both authors without blinding. Conflicts between authors were resolved by discussing each paper to reach a consensus. Inter-reviewer agreement on data extraction and quality assessment was evaluated by Cohen's kappa.
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Results

Study selection and characteristics
After exclusion of duplicate articles, the database search resulted in 86 articles. Hand searches of the bibliographies of the selected articles and relevant reviews added an additional 22 articles. Of these, only 13 fulfilled the inclusion and exclusion criteria and thus were included in this systematic review (Fig 1).5-8,10,13-20 The kappa scores before reconciliation for the selection, data extraction, and quality evaluation procedures were 0.846, 0.947, and 0.871, respectively, which indicated almost perfect agreement.
 

The characteristics of the 13 studies included in the review are presented in Table 1. Seven studies were case reports, three were case series, and three were retrospective cohort studies. Eleven studies5-8,13-17,19,20 reported occlusion setup for Class III deformity, and the other two studies10,18 reported occlusion setup for a mixed sample of various malocclusion. Five studies adopted 1-jaw (mandibular) surgery,5,6,16,17,20 five studies adopted 2-jaw surgery7,8,13-15 and three studies adopted 1- and 2-jaw surgery.10,18,19 All but one15 studies used rigid fixation.
 
Table1

Table1

A: ASO, mandibular anterior subapical osteotomy; B: BSSO, bilateral sagittal splitting osteotomy; C: mandibular contouring; G; genioplasty; I: IVRO, intraoral vertical ramus osteotomy; LF (1 or 2 p): Le Fort I osteotomy (1-piece or 2-piece); NA: not available; OF: orthodontics-first approach; SF: surgery-first approach; SAS: skeletal anchorage system

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In the 13 studies, the occlusion was suggested to set as Class I, II or III molar relationship in the sagittal dimension,5-8,10,14-16,18 deep bite or posterior open bite in the vertical dimension,8,19 little or no posterior crossbite10,13,18,19 or no complete posterior dental10 or skeletal crossbite8 in the transverse dimension, and stable posterior occlusion5-7,14 or at least three occlusal stops.13,17,19,20 However, none of the studies provided quantitive data of the surgical occlusion.
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Study quality analysis

The criteria examined in the 13 studies and the results of quality assessment according to a checklist are shown in Table 2. The studies reviewed had common methodological problems, and the all were categorized as having a low degree of quality.
 
Table 2

Table 2

Quality assessment of the included studies (N = 13)

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Discussion

Despite the evident advantages of surgery-first orthognathic surgery, it lacks worldwide popularity. One of the challenges for the surgery-first approach is the surgical occlusion setup. For example, in classic (i.e., orthodontics-first) approach pre-surgical orthodontic treatment brings maxillary and mandibular teeth into ideal relationships to their individual underlying skeletal bases,21,22 so the surgical occlusion is very close to the final occlusion (i.e., ideal occlusion) after complete pre-surgical orthodontic treatment. Thus, in orthodontics-first approach, surgical occlusion ideally is set as normal overjet and overbite,21,23,24 Class I canine and molar relationship,21-26 tooth-to-tooth contacts,22,26,27 and no occlusal interference.22,24,27 In contrast, in surgery-first approach, dental decompensation is deferred after surgery, so the surgical occlusion is different from the final occlusion. The surgical occlusion setup serves to foresee the tooth movements necessary to achieve an ideal occlusion after post-surgical orthodontic treatment. Thus, the occlusion is set as treatable malocclusion. Accurate surgical occlusion setup is important so surgery-first approach is not suggested to be managed by an orthodontist with limited experience in orthognathic surgery.8,9,18

This systematic review provided inconclusive evidence about the guidelines of surgical occlusion setup for Class III malocclusion using the surgery-first approach. The reasons for the discordant results are due to the heterogeneity of the samples in the selected studies, as shown by the variety of the deformity types, surgical design, and orthodontic mechanisms or techniques used in post-surgical orthodontics (Table 1), as well as the methodological deficiencies (Table 2). These are described in more details as below.

In the sagittal dimension, seven studies used first molars as a guide for antero-posterior dental position7,8,10,14-16,18 as incisors cannot be used as a guide in the sagittal dimension (i.e., incomplete horizontal skeletal correction) in contrast to classic surgical-orthodontic treatment, in which incisor decompensation is performed before surgery. Therefore, when nonextraction was performed in the lower arch the molar relationship could be either Class I when clockwise rotation of the palatal plane was used for upper incisor decompensation7,10,14,19 or Class II when upper premolar extraction10,19 or distalization of the maxillary dentition with Skeletal Anchorage System (SAS)5,6,16 was used for upper incisor decompensation.

Because arch coordination is deferred after surgery with the surgery-first approach, the occlusion setup in the transverse dimension often poses a significant challenge. Four studies used little or no posterior crossbite as a guide for transverse dental position10,13,18,19 because their philosophy was to achieve stable posterior occlusion and limit the post-surgical orthodontics to antero-posterior dental movement only. In other words, surgical occlusion setup should at most require only antero-posterior dental adjustment with minimal transverse or vertical dental movement.28 Therefore, severe arch incoordination, either skeletal or dental origin, are corrected by maxillary segmental surgery. On the other hand, maxillary segmental surgery is only indicated for severe skeletal crossbite (i.e, skeletal origin) in one study.8 In contrast to previous philosophy, posterior dental crossbite, either complete or incomplete, or mild skeletal crossbite are corrected by bending of orthodontic archwire, inter- or intra-arch elastics, transpalatal arch or lingual arch after surgery (i.e., the orthodontic way).

In the vertical dimension, only two studies8,19 mentioned deep overbite or posterior open bite as a guide for supero-inferior dental position in order to compensate for the space for dental alignment, and arch leveling and coordination after surgery. The posterior open bite is easier to correct than anterior open bite after surgery; therefore, surgical occlusion setup with anterior open bite should be avoided. The posterior open bite is also helpful for correction of posterior cross bite from buccoversion of maxillary molars (i.e., dental origin), which is quite common in Class III malocclusion, due to unlocked occlusion. On the other hand, one study suggested anterior open bite in order to achieve stable posterior occlusion.5

The need for stable surgical occlusion was emphasized in eight studies.5-7,13,14,17,19,20 However, definition of stable occlusion varied between studies; four studies defined stable occlusion as at least 3-point contact,13,17,19,20 whereas another four defined it as stable posterior occlusion.5-7,14 To prevent unstable jaw position from occlusal instability after surgery, six studies used an occlusal splint,5,13,15-17,20 another 2 studies used a chin cap,10,19 and the other four studies used intermaxillary elastics.8,14,15,17
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Conclusions

The studies in our systematic review yielded contradictory results and lacked high quality, therefore the scientific evidence was too weak to identify the guidelines for surgical occlusion setup in surgery-first orthognathic surgery for Class III malocclusion. Further high-quality studies are required. Accurate dental occlusion setup should be pursued to avoid severe postoperative occlusal instability, incomplete or excessive skeletal correction, or skeletal asymmetry. Employing a 3-dimensional virtual simulation process to assess the accuracy of occlusion setup in terms of skeletal deformity could establish new clinical guidelines for occlusion setup in the sagittal, vertical, and transverse dimensions.

Acknowledgements: The review was supported by the Ministry of Science and Technology, Taiwan (MOST105-2314-B-182-030) and the Chang Gung Memorial Hospital, Taiwan.
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REFERENCES

  1. Proffit WR, White RP, Sarver DM. Combining surgery and orthognathics: Who does what, when? in Proffit WR, White RP, Sarver DM (eds). Contemporary Treatment of Dentofacial Deformity. St Louis, MO, Mosby 2003:245-267.
  2. Luther F, Morris DO, Hart C. Orthodontic preparation for orthognathic surgery: how long does it take and why? A retrospective study. Br J Oral Maxillofac Surg. 2003;41:401-406.
  3. Diaz PM, Garcia RG, Gias LN, Aguirre-Jaime A, Perez JS, de la Plata MM et al. Time used for orthodontic surgical treatment of dentofacial deformities in white patients. J Oral Maxillofac Surg. 2010;68:88-92.
  4. Nurminen L, Pietila T, Vinkka-Puhakka H. Motivation for and satisfaction with orthodontic-surgical treatment: a retrospective study of 28 patients. Eur J Orthod. 1999;21:79-87.
  5. Nagasaka H, Sugawara J, Kawamura H, Nanda R. "Surgery first" skeletal Class III correction using the Skeletal Anchorage System. J Clin Orthod. 2009;43:97-105.
  6. Villegas C, Uribe F, Sugawara J, Nanda R. Expedited correction of significant dentofacial asymmetry using a "surgery first" approach. J Clin Orthod. 2010;44:97-103.
  7. Yu CC, Chen PH, Liou EJ, Huang CS, Chen YR. A Surgery-first approach in surgical-orthodontic treatment of mandibular prognathism--a case report. Chang Gung Med J. 2010;33:699-705.
  8. Liao YF, Chiu YT, Huang CS, Ko EW, Chen YR. Presurgical orthodontics versus no presurgical orthodontics: treatment outcome of surgical-orthodontic correction for skeletal Class III open bite. Plast Reconstr Surg. 2010;126:2074-2083.
  9. Hernandez-Alfaro F, Guijarro-Martinez R, Molina-Coral A, Badia-Escriche C. "Surgery first" in bimaxillary orthognathic surgery. J Oral Maxillofac Surg. 2011;69:e201-207.
  10. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg. 2011;69:771-780.
  11. Moher D, Liberati A, Tetzlaff J, Altman DG, The PG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS Medicine. 2009;6:e1000097.
  12. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283:2008-2012.
  13. Baek SH, Ahn HW, Kwon YH, Choi JY. Surgery-first approach in skeletal class III malocclusion treated with 2-jaw surgery: evaluation of surgical movement and postoperative orthodontic treatment. J Craniofac Surg. 2010;21:332-338.
  14. Villegas C, Janakiraman N, Uribe F, Nanda R. Rotation of the maxillomandibular complex to enhance esthetics using a "surgery first" approach. J Clin Orthod. 2012;46:85-91.
  15. Park KR, Kim SY, Park HS, Jung YS. Surgery-first approach on patients with temporomandibular joint disease by intraoral vertical ramus osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:e429-436.
  16. Aymach Z, Sugawara J, Goto S, Nagasaka H, Nanda R. Nonextraction "surgery first" treatment of a skeletal Class III patient with severe maxillary crowding. J Clin Orthod. 2013;47:297-304.
  17. Kim CS, Lee SC, Kyung HM, Park HS, Kwon TG. Stability of mandibular setback surgery with and without presurgical orthodontics. J Oral Maxillofac Surg. 2014;72:779-787.
  18. Yu HB, Mao LX, Wang XD, Fang B, Shen SG. The surgery-first approach in orthognathic surgery: a retrospective study of 50 cases. Int J Oral Maxillofac Surg. 2015;44:1463-1467.
  19. Gandedkar N, Chng C, Tan W. Surgery-first orthognathic approach case series: Salient features and guidelines. Journal of Orthodontic Science. 2016;5:35-42.
  20. Mah DH, Kim SG, Oh JS, You JS, Jung SY, Kim WG et al. Comparative study of postoperative stability between conventional orthognathic surgery and a surgery-first orthognathic approach after bilateral sagittal split ramus osteotomy for skeletal Class III correction. J Korean Assoc Oral Maxillofac Surg. 2017;43:23-28.
  21. Sinclair PM. Orthodontic considerations in adult surgical orthodontic cases. Dent Clin North Am. 1988;32:509-528.
  22. Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 1995;10:97-107.
  23. Jacobs JD, Sinclair PM. Principles of orthodontic mechanics in orthognathic surgery cases. Am J Orthod. 1983;84:399-407.
  24. Woods M, Wiesenfeld D. A practical approach to presurgical orthodontic preparation. J Clin Orthod. 1998;32:350-358.
  25. Worms FW, Isaacson RJ, Speidel TM. Surgical orthodontic treatment planning: profile analysis and mandibular surgery. Angle Orthod. 1976;46:1-25.
  26. Grubb J, Evans C. Orthodontic management of dentofacial skeletal deformities. Clin Plast Surg. 2007;34:403-415.
  27. Sabri R. Orthodontic objectives in orthognathic surgery: state of the art today. World J Orthod. 2006;7:177-191.
  28. Huang CS, Chen YR. Orthodontic principles and guidelines for the surgery-first approach to orthognathic surgery. Int J Oral Maxillofac Surg. 2015;44:1457-1462.
Table1

Table1

A: ASO, mandibular anterior subapical osteotomy; B: BSSO, bilateral sagittal splitting osteotomy; C: mandibular contouring; G; genioplasty; I: IVRO, intraoral vertical ramus osteotomy; LF (1 or 2 p): Le Fort I osteotomy (1-piece or 2-piece); NA: not available; OF: orthodontics-first approach; SF: surgery-first approach; SAS: skeletal anchorage system

View Hi-Res Image
Table 2

Table 2

Quality assessment of the included studies (N = 13)

View Hi-Res Image
  1. Proffit WR, White RP, Sarver DM. Combining surgery and orthognathics: Who does what, when? in Proffit WR, White RP, Sarver DM (eds). Contemporary Treatment of Dentofacial Deformity. St Louis, MO, Mosby 2003:245-267.
  2. Luther F, Morris DO, Hart C. Orthodontic preparation for orthognathic surgery: how long does it take and why? A retrospective study. Br J Oral Maxillofac Surg. 2003;41:401-406.
  3. Diaz PM, Garcia RG, Gias LN, Aguirre-Jaime A, Perez JS, de la Plata MM et al. Time used for orthodontic surgical treatment of dentofacial deformities in white patients. J Oral Maxillofac Surg. 2010;68:88-92.
  4. Nurminen L, Pietila T, Vinkka-Puhakka H. Motivation for and satisfaction with orthodontic-surgical treatment: a retrospective study of 28 patients. Eur J Orthod. 1999;21:79-87.
  5. Nagasaka H, Sugawara J, Kawamura H, Nanda R. "Surgery first" skeletal Class III correction using the Skeletal Anchorage System. J Clin Orthod. 2009;43:97-105.
  6. Villegas C, Uribe F, Sugawara J, Nanda R. Expedited correction of significant dentofacial asymmetry using a "surgery first" approach. J Clin Orthod. 2010;44:97-103.
  7. Yu CC, Chen PH, Liou EJ, Huang CS, Chen YR. A Surgery-first approach in surgical-orthodontic treatment of mandibular prognathism--a case report. Chang Gung Med J. 2010;33:699-705.
  8. Liao YF, Chiu YT, Huang CS, Ko EW, Chen YR. Presurgical orthodontics versus no presurgical orthodontics: treatment outcome of surgical-orthodontic correction for skeletal Class III open bite. Plast Reconstr Surg. 2010;126:2074-2083.
  9. Hernandez-Alfaro F, Guijarro-Martinez R, Molina-Coral A, Badia-Escriche C. "Surgery first" in bimaxillary orthognathic surgery. J Oral Maxillofac Surg. 2011;69:e201-207.
  10. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg. 2011;69:771-780.
  11. Moher D, Liberati A, Tetzlaff J, Altman DG, The PG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS Medicine. 2009;6:e1000097.
  12. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283:2008-2012.
  13. Baek SH, Ahn HW, Kwon YH, Choi JY. Surgery-first approach in skeletal class III malocclusion treated with 2-jaw surgery: evaluation of surgical movement and postoperative orthodontic treatment. J Craniofac Surg. 2010;21:332-338.
  14. Villegas C, Janakiraman N, Uribe F, Nanda R. Rotation of the maxillomandibular complex to enhance esthetics using a "surgery first" approach. J Clin Orthod. 2012;46:85-91.
  15. Park KR, Kim SY, Park HS, Jung YS. Surgery-first approach on patients with temporomandibular joint disease by intraoral vertical ramus osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:e429-436.
  16. Aymach Z, Sugawara J, Goto S, Nagasaka H, Nanda R. Nonextraction "surgery first" treatment of a skeletal Class III patient with severe maxillary crowding. J Clin Orthod. 2013;47:297-304.
  17. Kim CS, Lee SC, Kyung HM, Park HS, Kwon TG. Stability of mandibular setback surgery with and without presurgical orthodontics. J Oral Maxillofac Surg. 2014;72:779-787.
  18. Yu HB, Mao LX, Wang XD, Fang B, Shen SG. The surgery-first approach in orthognathic surgery: a retrospective study of 50 cases. Int J Oral Maxillofac Surg. 2015;44:1463-1467.
  19. Gandedkar N, Chng C, Tan W. Surgery-first orthognathic approach case series: Salient features and guidelines. Journal of Orthodontic Science. 2016;5:35-42.
  20. Mah DH, Kim SG, Oh JS, You JS, Jung SY, Kim WG et al. Comparative study of postoperative stability between conventional orthognathic surgery and a surgery-first orthognathic approach after bilateral sagittal split ramus osteotomy for skeletal Class III correction. J Korean Assoc Oral Maxillofac Surg. 2017;43:23-28.
  21. Sinclair PM. Orthodontic considerations in adult surgical orthodontic cases. Dent Clin North Am. 1988;32:509-528.
  22. Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in orthognathic surgery. Int J Adult Orthodon Orthognath Surg. 1995;10:97-107.
  23. Jacobs JD, Sinclair PM. Principles of orthodontic mechanics in orthognathic surgery cases. Am J Orthod. 1983;84:399-407.
  24. Woods M, Wiesenfeld D. A practical approach to presurgical orthodontic preparation. J Clin Orthod. 1998;32:350-358.
  25. Worms FW, Isaacson RJ, Speidel TM. Surgical orthodontic treatment planning: profile analysis and mandibular surgery. Angle Orthod. 1976;46:1-25.
  26. Grubb J, Evans C. Orthodontic management of dentofacial skeletal deformities. Clin Plast Surg. 2007;34:403-415.
  27. Sabri R. Orthodontic objectives in orthognathic surgery: state of the art today. World J Orthod. 2006;7:177-191.
  28. Huang CS, Chen YR. Orthodontic principles and guidelines for the surgery-first approach to orthognathic surgery. Int J Oral Maxillofac Surg. 2015;44:1457-1462.
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