title: Surgery first in orthognathic surgery: what have we learned? A comprehensive workflow based on 45 consecutive cases.
abstract: OBJECTIVE
  In some patients, "surgery first" (SF) may represent a reasonable approach for the expedited correction of a maxillofacial deformity. Based on the prospective evaluation of a large sample, this article provides a specific orthodontic and surgical protocol, discusses the benefits and limitations of this approach, and updates its indications.
  
  
  METHODS
  Forty-five patients were managed with an SF approach. Selected cases presented symmetrical skeletal malocclusions with no need for extractions or surgically assisted rapid palatal expansion. Periodontal or temporomandibular joint problems and management by an orthodontist without experience in orthognathic surgery were considered exclusion criteria. Virtual treatment planning included a 3-dimensional orthodontic setup. Standard orthognathic osteotomies were followed by buccal interdental corticotomies to amplify the regional acceleratory phenomenon. Miniscrews were placed for postoperative skeletal stabilization. Orthodontic treatment began 2 weeks after surgery. Archwires were changed every 2 to 3 weeks. At 12-month follow-up, patient satisfaction and orthodontist satisfaction were evaluated on a visual analog scale of 1 to 10. Descriptive statistics were computed for all study variables.
  
  
  RESULTS
  The studied sample consisted of 27 women and 18 men (mean age, 23.5 yr). The main motivation for treatment was the wish to improve facial esthetics. Bimaxillary surgery was the most common procedure. Mean duration of orthodontic treatment was 37.8 weeks, with an average of 22 orthodontic appointments. Mean patient and orthodontist satisfaction scores were 9.4 (range, 8 to 10) and 9.7 (range, 8 to 10), respectively.
  
  
  CONCLUSIONS
  The SF approach significantly shortens total treatment time and is very favorably valued by patients and orthodontists. Nevertheless, careful patient selection, precise treatment planning, and fluent bidirectional feedback between the surgeon and the orthodontist are mandatory.
authors.affiliation: Director, Institute of Maxillofacial Surgery, Teknon Medical Center Barcelona, Barcelona, Spain; Chair, Department of Oral and Maxillofacial Surgery, Universitat Internacional de Catalunya, Barcelona, Spain.
authors.forename: Federico
authors.initials: F
authors.lastname: Hernández-Alfaro
authors.affiliation: Institute of Maxillofacial Surgery, Teknon Medical Center Barcelona, Barcelona, Spain; Associate Professor, Department of Oral and Maxillofacial Surgery, Universitat Internacional de Catalunya, Barcelona, Spain. Electronic address: guijarro.raq@gmail.com.
authors.forename: Raquel
authors.initials: R
authors.lastname: Guijarro-Martínez
authors.affiliation: Fellow, Department of Orthodontics (International Diploma in Orthognathic Surgery and Surgical Orthodontics), Universitat Internacional de Catalunya, Barcelona, Spain. Private practice in Orthodontics, Valencia, Spain.
authors.forename: María A
authors.initials: MA
authors.lastname: Peiró-Guijarro
mesh_terms: D000293:Adolescent; D000328:Adult; D001863:Bone Screws; D002985:Clinical Protocols; D003815:Dentists / Q000523:psychology / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008312:Malocclusion, Angle Class II / Q000601:surgery*; D008313:Malocclusion, Angle Class III / Q000601:surgery*; D061646:Operative Time; D009971:Orthodontics, Corrective / Q000379:methods / Q000706:statistics & numerical data*; D056948:Orthognathic Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data*; D019340:Osteotomy, Le Fort / Q000706:statistics & numerical data; D059229:Osteotomy, Sagittal Split Ramus / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care; D010347:Patient Care Planning; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011446:Prospective Studies; D013165:Splints; D025321:Surgery, Computer-Assisted; D013997:Time Factors; D016896:Treatment Outcome; D064232:Visual Analog Scale; D057188:Workflow; D055815:Young Adult