Surgery First. Principy, vyâ hody a nevyâ hody Surgery First. Principles, advantages and disadvantages

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1 rocïnõâk24 ORTODONCIE Surgery First. Principy, vyâ hody a nevyâ hody Surgery First. Principles, advantages and disadvantages MUDr. TomaÂsÏ Hanzelka, Ph.D., MUDr. Josef KucÏ era, MUDr. Hana TycovaÂ, Doc. MUDr et MUDr. Rene Folta n, Ph.D. Stomatologicka klinika, 1. LeÂkarÏska fakulta UK a VFN, Praha Clinic of Stomatology, 1st Medical Faculty of Charles University and General University Hospital, Prague Souhrn Ortodonticko-chirurgicka leâ cï ba skeletaâ lnõâch vad je jednou z nejslozï iteï jsï õâch, ale zaâ rovenï nejzajõâmaveï jsï õâch cï aâ stõâ ortodoncie. Koncept ¹Surgery Firstª je novyâ postup, kteryâ se svou podstatou lisï õâ od tradicï nõâ standardnõâ kombinovaneâ terapie. Pacient hned na zacï aâ tku leâ cï by podstupuje ortognaâ tnõâ operaci, kteraâ harmonizuje skeletaâ lnõâ vztahy. PuÊ vodnõâ malokluze je prïi operaci nahrazena malokluzõâ novou, kteraâ je naâ sledneï rïesï ena ortodonticky. Absence faâ ze dekompenzace, okamzï itaâ zmeï na profilu a vyâ razneï kratsï õâ doba leâ cï by jsou hlavnõâ prïednosti Surgery First ve srovnaâ nõâ se standardnõâ kombinovanou terapiõâ. CõÂlem sdeï lenõâ je prïedstavit novyâ terapeutickyâ postup a uveâ st jeho vyâ hody, nevyâ hody, indikace a kontraindikace (Ortodoncie 2015, 24, cï. 2, s ). Abstract Orthodontic-surgical management of skeletal anomalies is one of the most complex and interesting parts of orthodontics. ¹Surgery Firstª concept is a new orthognathic approach, the core of which is different from the traditional standard combined therapy. At the very beginning of their treatment the patients undergo orthognathic surgery to harmonize skeletal relationships. The original malocclusion is substituted with the new one that is subsequently solved orthodontically. The absence of decompensation phase, immediate modification of a patient's profile, and significantly shorter treatment time represent the main advantages of the ¹Surgery Firstª approach compared to the standard combined therapy. The aim of the report is to introduce this new therapeutic method, and discuss its advantages, disadvantages, indications and contraindications (Ortodoncie 2015, 24, No. 2, p ). KlõÂcÏ ovaâ slova: ortognaâ tnõâ chirurgie, surgery first, skeletaâ lnõâ kotvenõâ, regionaâ lnõâ akceleracï nõâ fenomeâ n Key words: orthognathic surgery, surgery first, skeletal anchorage, regional acceleratory phenomenon U vod Od doby, kdy v roce 1848 provedl Hullihen prvnõâ ortognaâ tnõâ operaci, se mnoheâ zmeï nilo [1]. VeÏ tsï ina ortognaâ tnõâch operacõâ byla azï do 60. let minuleâ ho stoletõâ provaâdeï nabez ortodontickeâho prïedleâcï enõâ cï i doleâcï enõâ. Chrup v kompenzovaneâ m postavenõâ, ktereâ cï aâ stecï neï maskovalo skeletaâ lnõâ podklad vady, limitoval rozsah chirurgickeâ ho vyâ konu aurcï oval vyâ slednou estetiku oblicï eje (Obr. 1). MozÏnosti leâkarïuê tak byly velmi omezeneâ avyâ sledky leâ cï by z dnesï nõâho hlediskavõâce nezï kompromisnõâ. Introduction Since 1848, when Hullihen carried out the first orthognathic surgery, a lot of things have changed [1]. Up to the 60s of the last century, most orthognathic surgeries were performed without orthodontic treatment before or after the surgery. Dentition in the compensated position, that partially masked the underlying skeletal defect, limited the extent of surgical management, and determined the final facial esthetics (Fig. 1). Thus the options of surgeons were very limited, and the treatment results more than compromising redakce@orthodont-cz.cz

2 ORTODONCIE rocïnõâk24 Se vzruê stajõâcõâm mnozï stvõâm pacientuê azkusï enostõâ se zvysï ovaly i naâ roky z hlediskaestetickeâ ho afunkcï nõâho. DalsÏ õâm nevyhnutelnyâ m krokem v cesteï zalepsï õâm vyâsledkem bylo zapojenõâ ortodontickeâ leâcï by. PostupneÏ se vyvinul standardnõâ postup sklaâ dajõâcõâ se z ortodontickeâ dekompenzace naâ sledovaneâ ortognaâ tnõâ operacõâ aortodontickyâ m doleâ cï enõâm [2, 3] (Obr. 2). Ortogna tnõâ chirurgie je tak dnes bez pomoci ortodoncie neprïedstavitelnaâ azodpoveï dnyâ terapeutickyâ plaâ n se musõâ do podrobnostõâ zabyâvat obeï madisciplõânami [4]. RozhodujõÂcõÂm krokem, kteryâ umozï nil vznik modernõâho konceptu ªSurgery Firstª, bylo zavedenõâ rigidnõâch osteosyntetickyâ ch materiaâ luê do ortognaâ tnõâ chirurgie [5]. DalsÏ õâm duê lezï ityâ m krokem bylo rozsï õârïenõâ skeletaâ l- nõâho kotvenõâ. Kotevnõ mikrosï rouby akotevnõâ dlahy umozï nily zvyâsï it prïedvõâdatelnost leâ cï by [6]. PrÏitom praâ veï spolehliveâ prïedvõâdaâ nõâ je podmõânkou pro pouzï itõâ Surgery First. PrÏed samotnou ortognaâ tnõâ operacõâ pacient nepodstupuje zïaâ dneâ nebo pouze minimaâ lnõâ ortodontickeâ prïedleâ cï enõâ. Ortogna tnõâ operace na zacï aâ tku leâ cï by harmonizuje skeletaâ lnõâ vztahy a nahradõâ puê vodnõâ malokluzi malokluzõâ novou [6]. Ta je naâ sledneï rïesï enaortodontickou leâcï bou (Obr. 3). With the increasing number of patients and experience, the esthetic and functional demands were also increasing. Another inevitable step on the way for the better results was the inclusion of orthodontic treatment. Gradually, the standard process comprising orthodontic decompensation followed by orthognathic surgery and orthodontic after-treatment was developed [2, 3] (Fig. 2). Orthognathic intervention today requires orthodontic treatment, and the reliable therapeutic plan must deal in detail with both disciplines [4]. The critical step that made the origin of the modern Surgery First concept possible, was the introduction of rigid osteosynthetic materials to orthognathic surgery [5]. Another was the widespread use of skeletal anchorage. Temporary anchorage devices like miniscrews and miniplates increased the predictability of treatment results [6]. The reliable prediction is the precondition for the use of Surgery First. A patient does not undergo any or just minimum orthodontic pretreatment. Orthognathic surgery at the beginning of the therapy harmonizes skeletal relationships and substitutes the original malocclusion with a new one [6]. The new malocclusion is then solved through orthodontic therapy (Fig. 3). Obr. 1. Ortogna tnõâ chirurgie bez ortodontickeâ spolupraâ ce. Stav prïed operacõâ (a) a po operaci (b). Fig. 1. Orthognathic surgery without orthodontist's cooperation. The condition prior to surgery (a) and after surgery (b). 1a 1b 2a 2b 2c Obr. 2. Standardnõ ortodonticko-chirurgickaâ spolupraâ ce. PocÏ aâ tecï nõâ stav (a), stav po ortodontickeâ dekompenzaci (b), stav po ortognaâ tnõâ operaci (c). Fig. 2. Standard orthodontic-surgical cooperation. The original condition (a), the condition after orthodontic decompensation (b), the condition after orthognathic surgery (c). 3a 3b 3c Obr. 3. Surgery First. PocÏa tecï nõâ stav (a), stav po ortognaâ tnõâ operaci (b), stav po ortodontickeâ m doleâcï enõâ (c). Fig. 3. Surgery First. The original condition (a), the condition after orthognathic surgery (b), the condition after orthodontic posttreatment (c). redakce@orthodont-cz.cz 83

3 rocïnõâk24 ORTODONCIE Z hlediskakvality leâcï by maâ Surgery First pravdeï podobneï potenciaâ l dosahovat stejnyâ ch vyâ sledkuê jako standardnõâ kombinovanaâ terapie, ale absence ortodontickeâ dekompenzace, rychlaâ zmeï naprofilu akratsïõâ dobaleâcï by deï lajõâ ze Surgery First dalsï õâ z milnõâkuê kombinovaneâ ortodonticko-chirurgickeâ leâcï by [7, 8]. Doba leâcïby DobaleÂcÏ by je jednaz prvnõâch veï cõâ, kteraâ pacienta podstupujõâcõâho ortodonticko-chirurgickou leâcïbu zajõâmaâ. V prïõâpadeï Surgery First je celkovaâ dobaleâcïby kratsï õâ nezï u standardnõâ kombinovaneâ terapie. Na zaâkladeï odbornyâ ch publikacõâ lze dobu leâ cï by pomocõâ Surgery First pouze odhadovat na 12 azï 18meÏsõÂcuÊ [9] ve srovnaâ nõâ se 17 azï 35 meï sõâci [10] v prïõâpadeï standardnõâ kombinovaneâ terapie. DuÊ lezï itou roli maâ pravdeï podobneï pooperacï neï zvyâsï enyâ metabolickyâ obrat, kteryâ zvysï uje rychlost ortodontickeâ ho posunu zubuê [11]. Svou uâ lohu hraje takeâ upravenyâ vztah meï kkyâ ch tkaâ nõâ, jejichzï tlak po operaci puê sobõâ ve smeï ru plaâ novaneâ ho posunu zubuê. Vliv muêzïe mõât v neï kteryâch prïõâpadech i pouzï itõâ skeletaâ lnõâho kotvenõâ. Ve srovnaâ nõâ se standardnõâm postupem je takeâ vyâ hodneâ, zï e se okamzï ik zahaâ jenõâ ortodontickeâ leâ cï by muêzïe prïesneï prïizpuê sobit termõânu operace a potrïebaâm pacienta. Nevznikajõ tak obdobõâ, kdy pacient s nasazenyâ m fixnõâm aparaâ tem cï ekaâ prïipravenyâ nablõâzï õâcõâ se termõân operace, ani situace, kdy se kvuê li nedokoncï eneâ ortodontickeâ dekompenzaci termõân operace odklaâdaâ. Regiona lnõâ akceleracï nõâ fenomeâ n (angl. Regional Acceleratory Phenomenon, RAP) je termõân prïevzatyâ z ortopedickeâ traumatologie, kteryâ se vztahuje k reparativnõâm procesuê m probõâhajõâcõâm v kostnõâ tkaâ ni po prodeï laneâ m traumatu [12]. NejdrÏõÂve dochaâ zõâ k zvyâsï enõâ metabolickeâ ho obratu. ZvyÂsÏ enaâ prïestavba kostnõâ hmoty je doprovaâ zenaâ poklesem denzity azvyâsï enou porozitou kompakty. PrÏevla dajõâcõâ resorptivnõâ procesy jsou doprovaâ zeneâ zmnozï enõâm populace osteoklastuê aosteoblastuê. Stav vznikaâ neï kolik dnõâ po traumatu a nejvõâce se manifestuje beï hem prvnõâch 3 meïsõâcuê [9]. Klinicky nejvyâznamneï jsï õâm projevem RAP je zvyâsï enaâ mobilitazubuê. Taje maximaâ lnõâ v prvnõâm meï sõâci abeï hem cï tvrteâho meïsõâce se vracõâ zpeï t napuê vodnõâ uâ rovenï. V tomto obdobõâ je ortodontickaâ leâ cï bapravdeï podobneï rychlejsï õâ aefektivneï jsï õâ aje vhodneâ toho maximaâ lneï vyuzï õât. K ortodontickeâ leâcï beï pacienta po ortognaâ tnõâ operaci je vsï ak nutno prïistupovat opatrneï. Jako zvlaâsïteï nevhodneâ se autoruê m jevõâ pouzï õâvaâ nõâ silnyâ ch mezicï elistnõâch tahuê, ktereâ by mohly mõât v dobeï hojenõâ vliv napostavenõâ cï elistõâ. U prava funkce meï kkyâch tkaânõâ KompenzacÏ nõâ postavenõâ zubuê u skeletaâ lneï podmõâneï nyâ ch va d je vyâ sledkem fyziologickeâ reakce meï kkyâ ch From the viewpoint of the treatment quality, Surgery First may have the potential to achieve the same results as the standard combined therapy, however, the absence of orthodontic decompensation, the fast improvement of the profile, and shorter period of treatment make Surgery First another of the milestones of the combined orthodontic-orthognathic therapy [7, 8]. Treatment duration The length of treatment is one the first issues that the patients undergoing the orthodontic-orthognathic management are interested in. In case of Surgery First the overall length of the therapy is shorter than in the standard combined therapy. Based on the literature published we estimate the length of Surgery First treatment between 12 and 18 months [9] compared to months [10] of the standard combined therapy. The increased metabolic turnover after the surgery that accelerates orthodontic movement of teeth probably playes an important role [11]. Also the modified relationship of soft tissues the pressure of which works in the direction of the planned teeth movement after the surgery contributes to the process. A type of skeletal anchorage may also play its role. In comparison with the standard procedure it is advantageous that the beginning of the orthodontic treatment can be adjusted precisely according to the date of surgery and needs of a patient. This can avoid the prolonged periods when the patient wearing a fixed appliance is waiting for the upcoming surgery, and the situations when the date of surgery is postponed due to the unfinished orthodontic decompensation. Regional Acceleratory Phenomenon (RAP) is the term taken over from the orthopedic traumatology and refers to reparation processes going on in bone tissue after asuffered trauma[12]. First the metabolic turnover is increased. Accelerated reconstruction of bone tissue is accompanied with decreased density and increased porosity of the compact bone. Predominantly resorptive processes are accompanied with the increase in the population of osteoclasts and osteoblasts. This phenomenon begins several days following the trauma and manifests itself especially during the first 3 months [9]. The increased teeth mobility is the clinically most important manifestation of RAP. This mobility reaches its maximum in the first month, and during the fourth month it goes back to the original level. At this point the orthodontic treatment is probably faster and more effective, and therefore, it should be applied. However, the orthodontic treatment after the orthognathic surgery should be approached with caution. The application of strong intermaxillary pulls is considered inappropriate by the authors, as they may influence jaw positions during the healing period redakce@orthodont-cz.cz

4 ORTODONCIE rocïnõâk24 4a 4b 4c 4d Obr. 4. II. skeletaâ lnõâ trïõâda. Srovna nõâ pozitivnõâho sagitaâ lnõâho puê sobenõâ meï kkyâch tkaâ nõâ prïi Surgery First (b) anegativnõâho prïi standardnõâ kombinovaneâ terapii (c). VyÂchozõ stav (a), Surgery First (b), ortodontickaâ dekompenzace (c) a konecïnyâ stav (d). Fig. 4. Skeletal Class II. Comparison of the positive sagittal impact of soft tissues during Surgery First (b) and the negative one during the standard combined therapy (c). The initial condition (a), Surgery First (b), orthodontic decompensation (c) and the final situation (d). 5a 5b 5c 5d Obr. 5. III. skeletaâ lnõâ trïõâda. Srovna nõâ pozitivnõâho sagitaâ lnõâho puê sobenõâ meï kkyâch tkaânõâprïi Surgery First (b) anegativnõâho prïi standardnõâ kombinovaneâ terapii (c). VyÂchozõ stav (a), Surgery First (b), ortodontickaâ dekompenzace (c) a konecïnyâ stav (d). Fig. 5. Skeletal Class III. Comparison of the positive sagittal impact of soft tissues during Surgery First (b) and the negative one during the standard combined therapy (c). The initial condition (a), Surgery First (b), orthodontic decompensation (c) and the final situation (d). tkaâ nõâ, zubuê aalveolaâ rnõâ kosti naskeletaâ lnõâ diskrepanci. PrÏi standardnõâ kombinovaneâ terapii musõâme v raâmci ortodontickeâ dekompenzace tyto fyziologickeâ sõâly prïekonaâ vat. NaprÏõÂklad u pacientuê se III. skeletaâ lnõâ trïõâdou tlak dolnõâho rtu braâ nõâ protruzi dolnõâho frontaâ lnõâho uâ seku. U Surgery First po operaci dochaâ zõâ k nastolenõâ noveâho vztahu dentice a meï kkyâch tkaâ nõâ, ktereâ pakpuê sobõâ tlakem ve stejneâ m smeï ru jako fixnõâ aparaâ t (Obr. 4, 5). Skeleta lnõâ kotvenõâ Skeleta lnõâ kotvenõâ je soucï aâ stõâ modernõâ ortodoncie, ortognaâ tnõâ chirurgii nevyjõâmaje. DuÊ lezï itou roli hraje prïi standardnõâ kombinovaneâ terapii i prïi Surgery First. Chceme-li Surgery First pouzï õâvat pro veï tsï inu nasï ich operacï nõâch pacientuê anikoliv pouze pro vybraneâ prïõâpady, je skeletaâ lnõâ kotvenõâ nezbytnou nutnostõâ [6]. KromeÏ zkraâ cenõâ doby leâ cï by prïispõâvaâ i k jejõâ bezpecï nosti aprïedvõâdatelnosti. Da le umozïnï uje provaâ deï t ortodontickeâ pohyby, ktereâ by jinak byly jen teïzï ko mozïneâ, naprï. distalizace molaâ ruê asnõâzï enõâ pocï tu extrakcõâ premolaâ ruê. V neposlednõâ rïadeï muê zï e skeletaâ lnõâ kotvenõâ pomoci kompenzovat prïõâpadnou pooperacï nõâ recidivu cï i zbytkovyâ ruê st cï elistõâ [13]. PrÏedvõÂdatelnost Z hlediskazavaâ deï nõâ novyâ ch leâ cï ebnyâ ch postupuê nejsou nejduê lezïiteïjsï õâjejich vyâhody, ale jejich nevyâhody arizika, ve srovnaâ nõâ se standardnõâmi postupy. NejveÏ tsï õâ nebezpecï õâ Surgery First ve srovnaâ nõâ se standardnõâ kombinovanou terapii spocï õâvaâ v tom, zï e osï etrïujõâcõâ orto- Adjustment of soft tissues function Compensatory position of teeth in skeletally-based anomalies is the result of physiological reaction of soft tissues, teeth and alveolar bone to the skeletal discrepancy. In the standard combined therapy we have to overcome those physiological forces with the orthodontic decompensation. E.g. in the patients with skeletal Class III the pressure of lower lip hinders the protrusion of lower anterior segment. During Surgery First the new relationship between dentition and soft tissues is established after surgery so that they develop the pressure in the same direction together with fixed appliance (Fig. 4, 5). Skeletal anchorage Skeletal anchorage is an integral part of modern orthodontics as well as orthognathic surgery. It plays an important role both in the standard combined therapy and in the Surgery First approach. In case we want to use Surgery First for the majority of our indicated patients, not only for selective cases, the skeletal anchorage is an absolute necessity [6]. Apart from shorter treatment time it also contributes to the treatment safety and predictability. Further it allows to perform orthodontic movements that would be otherwise hardly possible, e.g. molar distalization, and to decrease the number of premolar extractions. Skeletal anchorage can also help to compensate the relapse following the surgery or residual growth of jaws [13]. redakce@orthodont-cz.cz 85

5 rocïnõâk24 ORTODONCIE dontistanebude schopen dosaâ hnout cõâle, podle ktereâ ho bylaplaâ novaâ naortognaâ tnõâ operace. V lepsï õâm prïõâpadeï je pak nutnaâ zmeï naterapeutickeâ ho plaâ nu, v horsïõâm prïõâpadeï leâcï bakoncï õâ estetickyâm cï i funkcï nõâm kompromisem. PouzÏ itõâ skeletaâ lnõâho kotvenõâ tato rizika vyâ raznyâ m zpuê sobem snizï uje azvysï uje tak prïedvõâdatelnost i bezpecï nost celeâ leâcï by [6, 13]. Jsou-li nasï e terapeutickeâ cõâle reaâ lneâ, muê zï eme jich s pomocõâ skeletaâ l- nõâho kotvenõâ bezpecï neï dosaâ hnout. To se tak staâvaâ klõâcï ovyâ m faktorem z hlediska plosï neâ ho rozsï õârïenõâ Surgery First. Bez jeho pouzï itõâ bychom Surgery First mohli indikovat pouze ve vybranyâch prïõâpadech. Distalizace Distalizace molaâruê je v indikovanyâch prïõâpadech podle Sugawary duê lezï itou soucï aâ stõâ postupu Surgery First. Je nutneâ zduê raznit, zï e primaâ rnõâm uâcï elem distalizace ve spojenõâ se Surgery First nenõâ pausïaâ lneï se vyhyâbat extrakcõâm premolaâruê. V rozhodovacõâm procesu - zda extrahovat nebo distalizovat - je duê lezïiteâ, kteryâ z postupuê povede rychleji k cõâli. UkaÂzÏe-li se jako uâ speïsïnaâ, mohlaby byât distalizace duê lezï ityâm prïõânosem prïi kombinovaneâ leâ cï beï II. skeletaâ lnõâ trïõâdy s protruzõâ dolnõâho frontaâ lnõâho uâ seku. V teï chto prïõâpadech je prïi standardnõâ kombinovaneâ terapii vhodnaâ extrakce dvou premolaâruê v dolnõâ cï elisti [13]. CÏ asto takeâ byâvaâ nutneâ prïed operacõâ extrahovat dolnõâ trïetõâ molaâ ry, pro jejichzï za rïazenõâ v hypoplastickeâ dolnõâ cï elisti nebyâvaâ dostatek mõâsta, a ktereâ zvysï ujõâ riziko sï patneâ ho rozlomenõâ dolnõâ cï elisti beï hem ortognaâ tnõâ operace. KonecÏ naâ artikulace ve III. trïõâdeï v molaâ rech je pak nevyâ hodnaâ akompromisnõâ. Hornõ druhyâ molaâ r nemaâ plnohodnotneâ ho antagonistu a je vhodnaâ jeho extrakce, trvalaâ retence nebo implantace v dolnõâm zubnõâm oblouku do mõâstatrïetõâho molaâ ru. V takovyâchprïõâpa- dech by byl postup Surgery First s distalizacõâ v dolnõâm zubnõâm oblouku a artikulacõâ v I. trïõâdeï dle Angleavelmi vyâ hodnyâ. PotvrdõÂ-li se tento zpuê sob jako uâ speï sï nyâ, meï l by byâ t, podobneï jako u pacientuê s obstrukcï nõâ spaâ nkovou apnoe, metodou volby. Do teâ doby je trïeba prïistupovat k distalizaci molaâ ruê v dolnõâ cï elisti s obezrïetnostõâ. Mola rovaâ intruze U Surgery First nemusõâ ortognaâ tnõâ operace nutneï vyrïesïit vsï echny probleâmy - rïesï enõâ neï kteryâch z nich muê zï e chirurg prïenechat ortodontistovi, kteryâ maâ v pooperacï nõâm obdobõâ najejich rïesï enõâ dostatek cï asu a prïõâzniveâ podmõânky v podobeï skeletaâ lnõâho kotvenõâ azvyâ sï e- neâ ho metabolickeâ ho obratu. PrÏõÂnosem pro pacienta muê zï e byâ t provedenõâ monomaxilaâ rnõâ operace mõâsto operace bimaxilaâ rnõâ, naprïõâklad dõâky molaâ roveâ intruzi v hornõâ cï elisti. U pacientuê s frontaâ lneï otevrïenyâm skusem, vyhovujõâcõâ polohou hornõâch rïezaâkuê abez trans- Predictability When introducing new therapeutic procedures we should put the main emphasis not on their advantages but on their disadvantages and risks in comparison with standard methods. The major risk of Surgery First is seen in the situation when an orthodontist is not able to achieve the goal according to which the orthognathic surgery was planned. In better case the therapeutic plan is modified, in a worse case the treatment finishes with an esthetic or functional compromise. The use of skeletal anchorage decreases these risks significantly, and thus increases the predictability as well as the safety of the overall treatment [6, 13]. We can achieve realistic therapeutic goals. This becomes the key factor in the widespread use of Surgery First. Without skeletal anchorage Surgery First would be indicated only in selected patients. Distalization According to Sugawara the molar distalization is a very important part of Surgery First in indicated cases. Needless to say that the primary goal of distalization accompanying Surgery First is not the avoidance of premolars extraction. When deciding whether to extract or not, the key factor is which of the procedures leads to the goal more effectively. Successful distalization could contribute to the treatment of skeletal Class II with lower incisor proclination. In the standard combined therapy of such cases the extraction of two lower premolars is recommended [13]. The extraction of lower third molars is frequently required prior to surgery - there is not enough space for the teeth in the hypoplastic mandible, and thus they increase the risk of a bad-split of the mandible during orthognathic surgery. The resulting Class III molar occlusion is thus unfavourable and compromising. The upper second molar does not have a corresponding antagonist, and therefore it is recommended to perform an extraction, permanent retention or implantation in the lower dental arch into the place of the third molar. In such cases Surgery First together with distalization in the lower dental arch and Class I molar occlusion is seen as very advantageous. In case this method proves to be successful, it should become - similarly to the patients with sleep apnea - the method of choice. Until then, we should be very cautious about the molar distalization in the mandible. Molar intrusion In Surgery First the orthognathic surgery does not have solve all problems - some of them may be left to the orthodontist who in the postoperative period has time and favourable conditions, i.e. skeletal anchorage and increased metabolic turnover, to correct them. The redakce@orthodont-cz.cz

6 ORTODONCIE rocïnõâk24 verzaâ lnõâ diskrepance, lze vertikaâ lnõâ probleâ m v indikovanyâch prïõâpadech rïesï it pomocõâ intruze lateraâ lnõâch uâ sekuê. Zdravotnõ aspekty leâcïby Surgery First prïinaâ sï õâ pacientovi ve srovnaâ nõâ se standardnõâ kombinovanou terapii i cï isteï zdravotnõâ vyâ hody. ZanejduÊ lezï iteï jsï õâ bychom pravdeï podobneï mohli oznacï it terapii obstrukcï nõâ spaâ nkoveâ apnoe (OSAS, Obstructive Sleep ApneaSyndrom), kteraâ s pomocõâ Surgery First muê zï e pravdeï podobneï prïispeï t ke snõâzï enõâ morbidity a mortality pacientuê. Mezi dalsï õâ pozitivnõâ zdravotnõâ aspekty patrïõâ nizïsï õâ pocï et ortodontickyâch extrakcõâ, zachovanaâ funkce stomatognaâ tnõâho systeâmu a v prïõâpadeï horsï õâ spolupraâ ce pacienta pravdeï podobneï i lepsï õâ stav chrupu a parodontu v duê sledku kratsï õâ doby leâcï by. CõÂlem ortodonticko-chirurgickeâ leâcï by pacientuê s OSAS je zvyâ sï enõâ pruê chodnosti dyâ chacõâch cest. Jednou z mozï nostõâ, jak toho dosaâ hnout, je chirurgickeâ prïedsunutõâ hornõâ i dolnõâ cï elisti. Vzhledem k rizikuê m souvisejõâcõâm s neleâcï enou OSAS je vhodneâ, aby pacient ortognaâ tnõâ operaci absolvoval v co nejkratsï õâm mozïneâ m termõânu. Z tohoto pohledu by meï lo byâ t Surgery First metodou volby. Proble m, kteryâ pacienta potenciaâ lneï ohrozï uje nazï ivoteï,muê zï e byâ t vyrïesï en beï hem neï kolika tyâ dnuê od urcï enõâ diagnoâ zy a vsï e ostatnõâ lze rïesï it a zï naâsledovneï. Cely terapeutickyâ postup se, s prïihleâ dnutõâm k obecnyâm pravidluêmleâcï by pacientuê s OSAS, nelisïõâod terapeutickeâ ho postupu pouzï õâvaneâ ho u ostatnõâch Surgery First pacientuê apodle naâ zoru autoruê by meï l byât u pacientuê steïzï kou spaâ nkovou apnoe standardem. Denta lnõâ zdravõâ Vliv ortodontickeâ leâcï by nazdravõâ zubuê aparodontu uâ zce souvisõâ s uâ rovnõâ uâ stnõâ hygieny. S prodluzïujõâcõâ se dobou leâ cï by cï asto klesaâ spolupraâ ce pacienta a zhorsï ujõâcõâ se uâ rovenï uâ stnõâ hygieny zvysï uje riziko vzniku demineralizacõâ, kazivyâch leâ zõâ a parodontopatiõâ. Surgery First vzhledem ke kratsï õâ dobeï leâcï by pravdeï podobneï snizï uje vyâsï e zmõâneï naâ rizika[14]. DalsÏ õâm faktorem prïispõâvajõâcõâm ke snõâzï enõâ teï chto rizik, muê zï e byâ t dobraâ spolupraâ ce pacientuê u Surgery First postupu [14]. Ta je daânacï asteï jsï õâmi kontrolami, rychlou uâ pravou estetiky oblicï eje aabsencõâ cï asto psychicky naâ rocï neâ ortodontickeâ dekompenzace. Opakovana leâcïba Surgery First muê zï e byâ t takeâ prïõânosem u pacientuê, kterïõâ v deï tstvõâ jizï prodeï lali kompenzacï nõâ ortodontickou leâ cï bu s prïõâpadnyâ mi extrakcemi premolaâ ruê au nichzï dõâky naâ sledneâ mu neprïõâzniveâmuruê stu cï elistõâ dosï lo k recidiveï vady prïesahujõâcõâ mozï nosti ortodontickeâ leâ cï by, prïõâpadneï takeâ u pacientuê, kterïõâ chteï jõâ rïesï it nevyhovujõâcõâ estetiku profilu oblicï eje [7]. Stav v teï chto prïõâpadech vy- benefit for a patient may be represented by performing rather a monomaxillary surgery instead of the bimaxillary one. Molar intrusion in the maxilla serves as an example. In patients with anterior open bite, appropriate position of upper incisors, and without any transversal discrepancy, the vertical problem can be solved (in indicated cases) with the intrusion of lateral segments. Health aspects of treatment In comparison with the standard combined therapy, Surgery First brings also health-related advantages to the patient. The most valid example is the therapy of Obstructive Sleep ApneaSyndrom (OSAS) that with the help of Surgery First may lower morbidity and mortality of patients. Other positive health aspects include lower number of orthodontic extractions, maintained function of stomatognathic system, and better condition of dentition and periodontium in less cooperative patients due to shorter treatment time. The aim of orthodontic-surgical management of OSAS is the increased airway volume. This may be achieved also by surgical advancement of both upper and lower jaw. With regard to the risks of the untreated OSAS, it is recommended that the patient undergoes the orthognathic surgery as early as possible. Surgery First should be the method of choice. The life threatening problem can be solved within several weeks since the diagnosis, and other problems may be worked upon subsequently. The therapeutic procedure, with regard to general rules for the treatment of patients with OSAS, does not differ from the procedure used in other Surgery First patients, and the authors believe Surgery First should become the standard for patients with severe obstructive sleep apnea. Dental health The impact of the orthodontic treatment on the dental and periodontal health is closely related to the level of oral hygiene. The longer the treatment, the smaller cooperation of patients and worse oral hygiene. The lower level of oral care increases the risk of demineralizations, caries lesions, and periodontal problems. With regard to a shorter period of treatment with Surgery First, the risks mentioned above are likely to minimize [14]. Another factor is a better patients cooperation during the Surgery First procedure [14]. This is due to more frequent check-ups, prompt improvement of facial esthetics, and absence of orthodontic decompensation that is frequently demanding in terms of aperson's psychology. Repeated therapy Surgery First may be beneficial in patients who underwent the orthodontic compensation treatment in their redakce@orthodont-cz.cz 87

7 rocïnõâk24 ORTODONCIE zï aduje kombinovanou ortodonticko-chirurgickou leâ cï bu s opeï tovnyâ m nasazenõâm fixnõâho aparaâ tu. Nutne je rïesï it kompenzacï nõâ postavenõâ zubuê. ZvlaÂsÏteÏ v prïõâpadeï, kdy byly beï hem puê vodnõâ leâcï by extrahovaâ ny premolaâ ry, se cï asto dostaâvaâ me do situace, kdy je trïeba mezializovat nebo distalizovat celeâ zubnõâ oblouky, chceme-li dosaâ hnout spraâ vneâ ho postavenõâ rïezaâkuê [14]. Vy zvou v takovyâ ch situacõâch byâ vaâ prïedevsï õâm deâ lkanoveâ leâcï by, kterou naâm muêzïe pomoci zkraâ tit praâveï Surgery First. Ortodonticke extrakce Ortodonticke extrakce jsou standardnõâ soucï aâ stõâ ortodontickeâ leâ cï by abez jejich pouzï itõâ bychom se v mnohaprïõâpadech jen teï zï ko obesï li. Jejich nizï sï õâ vyâ skyt vprïõâpadeï Surgery First tedy nelze povazï ovat za urcï ujõâcõâ vyâ hodu tohoto postupu. VyjõÂmku, kteraâ by vsï ak meï la byâ t jednoznacï nyâ m argumentem pro zvaâ zï enõâ Surgery First aneextrakcï nõâho postupu s distalizacõâ, tvorïõâ jizï zminï ovanõâ pacienti s diagnoâ zou II. skeletaâ lnõâ trïõâdy, u kteryâ ch jsou v raâ mci ortodontickeâ dekompenzace vhodneâ extrakce dvou premolaâruê v dolnõâ cï elisti s naâ slednou artikulacõâ ve III. trïõâdeï v molaâ rech. Psychologicke aspekty leâcïby JednõÂm z hlavnõâch duê voduê, procï veï tsï inapacientuê podstupuje ortognaâ tnõâ operaci, je zlepsï enõâ estetiky oblicï eje. OblicÏ ej je prostrïedkem verbaâ lnõâ i nonverbaâ lnõâ komunikace a vyâznamnyâm zpuê sobem tak ovlivnï uje mezilidskeâ vztahy. Jeho atraktivita maâ zaâ sadnõâ vliv na kvalitu zï ivotavcï etneï vzdeï laâ nõâ, zameï stnaâ nõâ cï i navazovaâ nõâ mezilidskyâ ch vztahuê. BohuzÏ el cï elistnõâ vady jizï ze sveâ podstaty porusï ujõâ neï kteraâ ze zaâ kladnõâch pravidel atraktivity - oblicï ej bez extreâ mnõâch odchylek, symetrie cï i prïõâmyâ profil. CÏ inõâ-li cï elistnõâ vada pacienta ve veï tsï ineï prïõâpaduê neatraktivnõâm, maâ vliv najeho psychickou pohodu akvalitu zï ivota. Pacienti podstupujõâcõâ ortodonticko-chirurgickou leâcï bu ve zvyâsï eneâ mõârïe vnõâmajõâsvuê j vzhled. U standardnõâ kombinovaneâ terapie dochaâ zõâ ve faâ zi dekompenzace u III. skeletaâ lnõâ trïõâdy k vyârazneâ mu zhorsï enõâ profilu pacienta, kteryâ toto obdobõâ vnõâmaâ jako horsï õâ astresujõâcõâ cïaâstleâcï by. Vznika zde rozpor mezi tõâm, co chce pacient aco musõâ deï lat leâkarï: Pacient si prïeje rychleâ zlepsï enõâ vzhledu, ale leâkarï musõâ jeho vzhled v raâ mci dekompenzace jeden azï dvaroky zhorsï ovat. MozÏ nost vyhnout se ortodontickeâ dekompenzaci ajejõâho negativnõâho vlivu naestetiku oblicï eje, se tak staâ vaâ silnyâ m argumentem pro pouzï itõâ postupu Surgery First. Druhy m argumentem je skutecï nost, zï e pacientuê v hlavnõâ probleâ m - vzhled oblicï eje - je rïesï en hned nazacïaâ tku leâcï by. To nadruhou stranu muêzïe veâ st ke ztraâteï motivace dokoncï it samotnou ortodontickou leâcï bu, childhood with premolars extractions. Due to the following and unfavourable growth of jaws in some of them, the anomaly relapsed and its solution is beyond the capability of orthodontic treatment, or they wish to correct the face profile esthetics [7]. Thus the condition requires the combined orthodontic-surgical therapy with the repeated bonding of a fixed appliance. The compensatory position of teeth must be solved. Especially in those cases where premolars were extracted during the original treatment, we often have to mesialize or distalize the whole dental arches to achieve the correct position of incisors [14]. The length of the new treatment poses a challenge which may be solved with Surgery First. Orthodontic extractions Orthodontic extractions are the standard component of orthodontic treatment, in many cases they are unavoidable. Therefore, the lower number of extractions applied during the Surgery First procedure cannot be viewed as the decisive advantage of the method. The exception that should be a univocal argument for Surgery First and non-extraction procedure with distalization are skeletal Class II patients. Within the orthodontic decompensation, in these patients are recommended extractions of two premolars in the mandible with subsequent Class III occlusion in molars. Psychological aspects One of the main reasons for undergoing orthognathic surgery is the improvement of facial esthetics. Face serves as a mean of both verbal and non-verbal communication, and thus significantly affects interpersonal relationships. Facial attractiveness influences significantly the life quality including education, employment or relationships. Unfortunately, skeletal anomalies by their essence disturb some of the basic rules of attractiveness - face without extreme deviations, symmetry, or straight profile. In case a skeletal anomaly makes the patient's face unattractive, it influences ones psychology and quality of life. Patients undergoing orthodontic-surgical therapy are very sensitive regarding their appearance. During the standard combined therapy in skeletal Class III a patient's profile is significantly affected in the decompensation phase, which is very stressful for them. There is the clash between what the patient wants and what the orthodontist has to do. Patients wish the prompt improvement of their appearance, however, orthodontists have to worsen their appearance throughout the decompensation period which may last for a year or two. The potential avoidance of orthodontic decompensation thus becomes a strong argument for the use of Surgery First. Another argument is the fact that the pa redakce@orthodont-cz.cz

8 ORTODONCIE rocïnõâk24 tak jak to v neï kteryâch prïõâpadech pozorujeme u pacientuê leâ cï enyâ ch standardnõâm zpuê sobem. Indikace IndikacÏ nõâ spektrum pacientuê ve srovnaâ nõâ se standardnõâ kombinovanou terapiõâ do znacï neâ mõâry zaâ visõâ nazkusï enostech osï etrïujõâcõâho leâkarïe. NeÏ kterïõâ autorïi indikujõâ Surgery First pouze v prïõâpadeï pravidelnyâ ch obloukuê, minimaâ lnõâho steï snaâ nõâ, plocheâ Speeovy krïivky aneexistujõâcõâch transverzaâ lnõâch probleâ muê [14], jinõâ pouzï õâvajõâ Surgery First k leâcïbeïteâmeïrïvsï ech pacientuê. PrÏi pouzï itõâ skeletaâ lnõâho kotvenõâ lze rïõâci, zï e kromeï neïkolikamaâ lo vyâ jimek muê zï e byâ t indikovaâ no Surgery First u stejneâ ho spektrapacientuê jako standardnõâ kombinovanaâ terapie [8]. PrÏesto je vhodneâ zduê raznit cï tyrïi indikace, u kteryâchby meïlobyât Surgery First vzï dy zvazïovaâ no naprvnõâm mõâsteï. NejduÊ lezï iteï jsï õâ je vzhledem ke zdravotnõâmu duê voduê m terapie obstrukcï nõâ spaâ nkoveâ apnoe [6]. Rychle kauzaâ lnõâ rïesï enõâ probleâ mu, ktereâ Surgery First nabõâzõâ, muêzïebyât pro pacienta rozhodujõâcõâ. Jako dalsï õâ dobraâ indikace pro Surgery First se nabõâzõâ jizï zminï ovanaâ terapie II. skeletaâ lnõâ trïõâdy. PotvrdõÂ-li se dobraâ uâ speïsï nost distalizace molaâruê v dolnõâ cï elisti v pooperacï nõâm obdobõâ, bude mozïneâ se v indikovanyâchprïõâ- padech s pomocõâ skeletaâ lnõâho kotvenõâ vyhnout extrakcõâm dolnõâch premolaâ ruê a naâ sledneâ artikulaci ve III. trïõâdeï v molaâ rech. CÏ aâ stecïneï psychologickou indikacõâ je leâcï baiii. skeletaâ lnõâ trïõâdy [8]. Absence dekompenzace je v teâ to situaci, zvlaâ sï teï z pohledu pacienta, silnyâ m argumentem. Poslednõ indikacõâ je leâcï baasymetriõâ. Ortodonticka dekompenzace byâvaâ v takovyâch prïõâpadech velmi naârocï naâ abez skeletaâ lnõâho kotvenõâ cï asto sï patneï proveditelnaâ. PodobneÏ jako u III. skeletaâ lnõâ trïõâdy je zde takeâ vyâraznyâ psychologickyâ motiv. Kontraindikace AbsolutnõÂch kontraindikacõâ Surgery First nenõâ mnoho avelkaâ veïtsï inaz nich se daâ odstranit pouzï itõâm skeletaâ lnõâho kotvenõâ apomocõâ minimaâ lnõâho ortodontickeâho prïedleâcï enõâ. PrÏõÂkladem je nedostatecï naâ divergence korïenuê v mõâsteï plaâ novaneâ osteotomie prïi segmentaâ lnõâ operaci hornõâ cï elisti. Ortogna tnõâ operaci je v takoveâ m prïõâpadeï mozï no proveâ st a zï po uâ praveï sklonu zubuê v okolõâ plaâ novaneâ osteotomie. DalsÏ õâ kontraindikacõâ je terapie II. trïõâdy, 2. oddeï lenõâ, kde by bylo v raâ mci operace nutneâ vytvorïit vyâraznyâ obraâ cenyâ skus. Jeho uâ prava muêzïebyât velmi naâ rocïnaâ anavõâc v takoveâ situaci odpadaâ jednaz hlavnõâch vyâ hod Surgery First - okamzï iteâ zlepsï enõâestetiky oblicï eje. V takoveâm prïõâpadeï je pravdeï podobneï vhodneâ postupovat standardnõâ cestou nebo cestou minimaâ lnõâho ortodon- tient's major problem - the facial appearance - is solved as early as at the beginning of the therapy. On the other hand, this may also lead to the lack of motivation to complete the individual orthodontic treatment, as we can observe in some patients undergoing the standard procedure. Indications The spectrum of patients indicated for Surgery First compared to those indicated for the standard combined therapy depends to a large extent on an orthodontist's experience. Some authors indicate Surgery First only in case of regular dental arches, minimum crowding, flat curve of Spee, and absence of transversal problems [14], others apply Surgery First in almost all their patients. With the use of skeletal anchorage we can say that, save for minor exceptions, Surgery First can be indicated in virtually the same spectrum of patients as the standard combined therapy [8]. Nevertheless, we should point out the four indications in which Surgery First should be the method of the first choice. With regard to medical reasons for the therapy of obstruction sleep apnea syndrome the indication of Surgery First is the most important [6]. Fast and causal solution of the problem offered by Surgery First may be decisive for the patient. Another appropriate indication is for the therapy of skeletal Class II. On condition that the molar distalization in the mandible after the surgery proves successful, then in the indicated cases and with skeletal anchorage, we could avoid extractions of lower premolars and subsequent Class III occlusion in molars. The skeletal Class II therapy represents a partially psychological indication [8]. The absence of decompensation phase is a very strong argument, especially for the patients. The last indication is the therapy of mandibular asymmetry. In such cases the orthodontic decompensation is usually very demanding, and without skeletal anchorage virtually impossible to perform. Psychological aspect plays an important role in these cases. Contraindications There are only a few absolute contraindications to the Surgery First approach, and most of them can be eliminated by the use of skeletal anchorage and minimal orthodontic pretreatment. The example is insufficient roots divergence at the place of the planned osteotomy during the segmental surgery of the maxilla. Orthognathic management is performed only after the adjustment of the teeth inclination near the planned osteotomy. redakce@orthodont-cz.cz 89

9 rocïnõâk24 ORTODONCIE tickeâho prïedleâ cï enõâ, v raâ mci ktereâ ho je protrudovaâ n hornõâ frontaâ lnõâ uâ sek. V literaturïe cï asto zminï ovanou kontraindikacõâ Surgery First je vyâraznaâ SpeeovakrÏivka, kteraâ komplikuje plaâ novaâ nõâ definitivnõâ polohy dolnõâ cï elisti [6] nejen z hlediskasagitaâ lnõâho, ale i z hlediska vertikaâ lnõâho. Proto muê zïe byât duê vodem pro indikaci standardnõâ kombinovaneâ terapie. Transverza lnõâ diskrepance cï elistõâ je neï kteryâmi autory povazï ovaâ natakeâ za kontraindikaci Surgery First [14]. DuÊ vodem je opeï t slozï iteâ plaâ novaâ nõâ definitivnõâ sagitaâ lnõâ i vertikaâ lnõâ polohy dolnõâ cï elisti. Po sï õârïkoveâ harmonizaci obloukuê apo odstraneï nõâ prïedcï asnyâ ch kontaktuê v lateraâ lnõâch uâ secõâch dochaâ zõâ k autorotaci dolnõâ cï elisti, kteraâ je u terapie III. skeletaâ lnõâ trïõâdy povazï ovaâ na za recidivu vady [14]. Na rozdõâl od standardnõâ kombinovaneâ terapie je s autorotacõâ trïebapocï õâtat jizï v raâ mci tvorby terapeutickeâ ho plaâ nu anemeï li bychom ji zarecidivu vady oznacï ovat. ZaÂveÏr Surgery First je velmi slibnyâ terapeutickyâ postup charakteristickyâ absencõâ ortodontickeâho prïedleâcï enõâ. Hned nazacï aâ tku leâ cï by pacient podstupuje ortognaâ tnõâ operaci, kteraâ normalizuje skeletaâ lnõâ vztahy cï elistõâ. BeÏhem tohoto chirurgickeâho zaâ kroku je puê vodnõâ malokluze nahrazena malokluzõâ novou, kteraâ je naâ sledneï rïesï enaortodonticky. Surgery First s sebou prïinaâsï i celou rïadu vyâhod. Mezi nejcï asteï ji zminï ovaneâ patrïõâ okamzï itaâ zmeï naprofilu, absence ortodontickeâ dekompenzace a kratsï õâ doba leâ cï by. Hlavnõ nevyâ hodou Surgery First je neexistence dlouhodobyâ ch studiõâ, kteraâ naâ s nutõâ k problematice prïistupovat s rozvahou a kriticky. DalsÏ õâm probleâ mem je slozïitost plaâ novaâ nõâ celeâ leâcï by, kteraâ muêzï e zvysï ovat riziko chyby se vsï emi duê sledky pro funkci, estetiku i stabilitu leâcï by. AutorÏi nemajõâ komercï nõâ, vlastnickeâ nebo financï nõâ zaâ jmy na produktech nebo spolecï nostech popsanyâ ch v tomto cïlaâ nku. Another contraindication is the therapy of Class II, Division 2, where the surgery would result in asignificant anterior crossbite which may consequently be rather demanding to correct; moreover one of the main advantages of Surgery First is lost in such condition - the prompt improvement of face esthetics. In this case it is better to decide for the standard procedure or for aminimum orthodontic pretreatment resulting in the upper anterior segment protrusion. The distinct curve of Spee, complicating the planning of the final position of the mandible [6] both sagittally and vertically, is often mentioned in literature as the contraindication of the Surgery First method. Some authors also consider transversal jaws discrepancy as contraindication [14]. The reason is the problematic planning of the final sagittal and vertical position of the mandible. After the dental arches width harmonization, and after the removal of premature contacts in the lateral segments, there occurs the mandible autorotation which is in the therapy of skeletal Class III considered as the relapse of anomaly [14]. Unlike the standard combined therapy, the autorotation should be taken into account already during the creation of the therapeutic plan, and should not be seen as the relapse of anomaly. Conclusion Surgery First represents avery promising therapeutic approach characterized by the absence of orthodontic pretreatment. Immediately at the beginning of the therapy a patient undergoes an orthognathic surgery leading to normalization of jaws skeletal relationships. During the surgery the original malocclusion is substituted with a new malocclusion that is subsequently solved orthodontically. Surgery First brings about a number of advantages, including the prompt improvement of the patientcë s profile, absence of orthodontic decompensation, and a shorter period of treatment. The main disadvantage of Surgery First is seen in the lack of long-term follow-up studies. Therefore, we have to decide very carefully and critically. Another problem may be the complexity of the whole therapy planning, which may increase the risk of error together with all consequences regarding the function, esthetics and stability of the treatment. The authors have no commercial, ownership or financial interests in the products or companies mentioned in the article redakce@orthodont-cz.cz

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