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Year : 2015  |  Volume : 7  |  Issue : 5  |  Page : 101-106  

Surgery preceding orthodontics in bimaxillary cases

Department of Oral Surgery, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission31-Oct-2014
Date of Decision31-Oct-2014
Date of Acceptance09-Nov-2014
Date of Web Publication30-Apr-2015

Correspondence Address:
Dr. B Saravana Kumar
Department of Oral Surgery, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-7406.155840

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Orthognathic surgery is performed to alter the shape of the jaws to increase the facial esthetic and improve the occlusions. Surgery prior orthodontics reduces the total length of the treatment of the patients, followed by orthodontics treatment. Advantages is positive outcome in short period of time. Surgical procedure includes Anterior Maxillary osteotomy and Anterior subapical mandibular osteotomy. Complication includes haemorrhage, paraesthesia, malunion of bone, etc.

Keywords: Anterior maxillary osteotomy, anterior subapical mandibular osteotomy, orthognathic surgery

How to cite this article:
Kumar B S, Dakir A, Krishnan B, Ebenezer V, Muthumani, Kumar K, Arvind W. Surgery preceding orthodontics in bimaxillary cases. J Pharm Bioall Sci 2015;7, Suppl S1:101-6

How to cite this URL:
Kumar B S, Dakir A, Krishnan B, Ebenezer V, Muthumani, Kumar K, Arvind W. Surgery preceding orthodontics in bimaxillary cases. J Pharm Bioall Sci [serial online] 2015 [cited 2022 Oct 5];7, Suppl S1:101-6. Available from:

Orthognathic surgery is the term used to describe surgical movement of the tooth-bearing segments of the maxilla and mandible. Patients for orthognathic surgery have a dentofacial deformity that cannot be ideally treated with orthodontic therapy alone. Candidates have malocclusions caused by skeletal discrepancies secondary to congenital anomalies or trauma. Patients have high levels of satisfaction with the esthetic and functional outcomes, especially if they were accurately informed about all aspects of their treatment. [1] One study found that one-third of patients rated the orthodontics as the worst part of their orthognatic treatment owing to the appliances visibility and discomfort and the length of treatment. [2] The performance of surgery first prior to orthodontics treatment was first proposed by Nagasaka et al. [2] Patients complains of forwardly placed jaws. Patients wants to fix the problem without undergoing through lengthy process of orthodontics treatment [Figure 1], [Figure 2], [Figure 3] and [Figure 4]
Figure 1: Preoperative photographs

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Figure 2: Intra oral preoperative photographs

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Figure 3: (a)Preoperative photograph (b)Postoperative photograph

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Figure 4: Operative photograph

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   Anterior Segmental Maxillary Osteotomy Top

The anterior segmental maxillary osteotomy (ASMO) was first published by Cohn Stock in 1921. [3],[4]

Currently three methods have been used the Wassmund, Wunderer, and down fracture methods. [5],[6]

  • Wassmund - involves only subperiosteal tunneling and no flaps and maintains both the palatal and labial vasculature.
  • Wunderer - palatal flap elevation with preservation of the labial pedicle. The Wunderer techniques are useful for anteroposterior repositioning
  • Down-fracture techniques described by Cupar-circum-vestibular incision for labial osteotomies and tunneling for the palatal osteotomy and later modified by Bell and Epker. Down-fracture method is recommended when superior or combined superior and posterior repositioning is required.

Anterior segmental maxillary osteotomy is usually indicated for excessive vertical or sagittal development of the maxillary alveolar process in patients where the posterior teeth relationship is acceptable, this kind of patients have anterior gummy smiles with increased overjet and deep overbite.

Indications for anterior maxillary osteotomy

  • Bimaxillary dentoalveolar protrusion
  • Anterior open bite
  • Excessive inclination of anterior teeth
  • Excessive vertical or anteroposterior development of the maxillary dentoalveolar process in patients where relationships between the posterior teeth are acceptable and
  • Duration of treatment, a relative indication in the Asian Indian population, in so far as some patients want quick results and do not have adequate time for a formal orthodontic correction.

Surgical procedure

The procedure was carried out under general anesthesia with nasal intubation, local infiltration with 2% lignocaine HCl with adrenaline 1:80000 is administered in maxillary vestibule. Standard Cupar incision was placed from first premolar to premolar [Figure 5] and [Figure 6].
Figure 5: Incision in maxilla

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Figure 6: Incision in maxilla

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The mucoperiosteum was elevated through this incision to expose the pyriform aperture and anterior wall of the maxilla up to the canine fossa. [7] Upper first premolars were extracted on both the sides.

Palatal tunneling was done from the extraction socket converging at midline. Keeping the gingivoperiosteal flap intact and well retracted vertical maxillary osteotomy was carried out from the socket of extracted premolars to pyriform aperture bilaterally followed by the palatal Osteotomy [Figure 7]. [7] Elevation is performed [Figure 8]. After completing the Osteotomy [Figure 9], [Figure 10], [Figure 11], [Figure 12] and [Figure 13], anterior maxillary segment was down fractured and Superior and posterior repositioning was done. Excess bone was removed from anterior segment or the adjacent maxilla.
Figure 7: Operative photographs

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Figure 8: Elevation

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Figure 9: Osteotomy cut in maxilla

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Figure 10: Osteotomy cut in mandible

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Figure 11: Osteotomy cut in mandible

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Figure 12: Osteotomy cut

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Figure 13: Osteotomy cut in mandible

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Wound closure was done with 3-0 vicryl.

Severe skeletal open bite malocclusions cannot be corrected by orthodontics means alone. The resistance by tongue and perioral muscle functions, high potential of vertical relapse of extrusion limited the success of mechanotherapy.

The use of anterior maxillary osteotomy for the correction of open bite, closed bite, underdeveloped maxilla, and protruding maxilla was advocated by Mohnac. The procedure could be used concurrently with the mandibular correction of class II and class III malocclusions. According to Parnes (1966) the major advantage of surgical correction over the orthodontics was the "time factor." The first report of an anterior segmental anterior maxillary osteotomy (ASMO) was published by Cohn-Stock.

Anterior subapical mandibular osteotomy

Hullihen (1949) was the first person to perform an anterior subapical osteotomy to correct anterior open bite. [8],[9]


  • To advance or retrude the lower anterior segment
  • To close anterior open bite.


An incision is placed 15 mm in the vestibule of the lower lip [Figure 14], [Figure 15], [Figure 16] and [Figure 17]. Incision extends from the first premolar to the opposite premolar. Anterior part of the mandible is degloved to the inferior border.
Figure 14: Vestibular incision placed in mandile

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Figure 15: Mucoperiosteal flap elevated in mandible

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Figure 16: Incision placed in mandible

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Figure 17: Elevation in mandible

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Dissection is performed till the mental neurovascular bundles is visualized. Osteotomy is performed by straight hand piece [Figure 11] and [Figure 13]. After the vertical cut is completed, a horizontal cut is made connecting the vertical cuts 5 mm below the apices of the anterior mandibular teeth. Osteotomy is completed using a thin osteotome or a spatula chisel. Plating is done in maxilla and mandible [Figure 18], [Figure 19] and [Figure 20].
Figure 18: Plating done in maxilla and mandible

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Figure 19: Plating done in maxilla

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Figure 20: Plating done in mandible

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  • Modified osteotomy - a midline osteotomy may be incorporated in case of midline diastema
  • Extended osteotomy - osteotomy can be extended up to the existing edentulous space. Cut segment can be mobilized with gentle pressure at the osteotomy site.

Closure is done in a layered fashion. 4-0 resorbable chromic sutures are placed submucosally, followed by vertical mattress sutures to close the mucosal layer.

   Discussion Top

A dramatic improvement in facial esthetics and occlusal function was realized with the completion of treatment. The lip competency, gingival exposure on smile and facial contour was significantly improved in a shorter period. The "surgery first" concept was introduced by Nagasaka et al. in 2005. The patient did not undergo any previous orthodontics preparation.

According to Parnes (1966) the major advantage of surgical correction over the orthodontics was the "time factor." Surgical orthodontics treatment includes two phases: A preoperative preparation in which most of the orthodontics movements are performed to achieve a precise, stable occlusion and postoperative phase for minor adjustments. Pretreatment last for 15-17 months or up to 2 years. [10] Post phase last for 7-12 months. [11],[12]

On other hand if surgery is performed first, the total treatment plan is reduced. Nagasaka et al. reported that the total treatment shortened to 12 months, less than the average time needed for traditional preoperative orthodontics alone. [2],[13]

   Conclusion Top

The surgery first corrects the skeletal problem from the beginning. This concept of surgery first has the advantage of immediate patient satisfaction comparing to traditional orthodontic treatment [Figure 21] and [Figure 3]. This gives the patients a better self-esteem and positive satisfaction in a shorter period in surgery first treatment.
Figure 21: Postoperative photographs

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   References Top

Cunningham SJ, Hunt NP, Feinmann C. Perceptions of outcome following orthognathic surgery. Br J Oral Maxillofac Surg 1996;34:210-3.  Back to cited text no. 1
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.  Back to cited text no. 2
Nurminen L, Pietilä 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.  Back to cited text no. 3
Leibold DG, Tilson HB, Rask KR. A subjective evaluation of the re-establishment of the neurovascular supply of teeth involved in anterior maxillary osteotomy procedures. Oral Surg Oral Med Oral Pathol 1971;32:531-4.  Back to cited text no. 4
Rosenquist B. Anterior segmental maxillary osteotomy. A 24-month follow-up. Int J Oral Maxillofac Surg 1993;22:210-3.  Back to cited text no. 5
Jayaratne YS, Zwahlen RA, Lo J, Cheung LK. Facial soft tissue response to anterior segmental osteotomies: A systematic review. Int J Oral Maxillofac Surg 2010;39:1050-8.  Back to cited text no. 6
Wassmund M. Lehrbueh der Praktischen Chirurgie des Mundcs und der Kicfer. Vol. 1. Leipzig: Hermann Meusser; 1935.  Back to cited text no. 7
Wunderer S. Die prognathie operation mittels frontal gestieltem maxillafeagment. Osterr Z Stomatol 1962;59:98.  Back to cited text no. 8
McNiell RW. Surgical orthodontic correction of open - Bite malocclusion. Am J Orthod Dentofacial Orthop 1973;64:108-11.  Back to cited text no. 9
Flanary CM, Alexander JM. Patient responses to the orthognathic surgical experience: Factors leading to dissatisfaction. J Oral Maxillofac Surg 1983;41:770-4.  Back to cited text no. 10
Diaz PM, Garcia RG, Gias LN, Aguirre-Jaime A, Pérez 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.  Back to cited text no. 11
Luther F, Morris DO, Karnezi K. Orthodontic treatment following orthognathic surgery: How long does it take and why? A retrospective study. J Oral Maxillofac Surg 2007;65:1969-76.  Back to cited text no. 12
Dowling PA, Espeland L, Krogstad O, Stenvik A, Kelly A. Duration of orthodontic treatment involving orthognathic surgery. Int J Adult Orthodon Orthognath Surg 1999;14:146-52.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21]

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