Surgery First Protocol

[Dopesaint]

Hello everyone,

I have consulted with 2 surgeons who can offer surgery first protocol for a class 2 malocclusion. (Surgery would be Double Jaw Surgery + Genio + CCW from both)

I asked surgeon A if pre-orthodontic work would yield more projection if decompensation (extraction of bottom pre-molars and teeth shifted back) is performed first and he stated yes.

However, surgeon B stated that it doesn't matter if surgery first is performed or if pre-orthodontic work is performed first, in the end, the same end result will be achieved.

Am I better off going with surgery first and avoiding the extraction of my bottom pre-molars? I'm afraid the decompensation would be a waste of time and teeth.

Please any help or insight would be greatly appreciated, thanks in advance.

[Dogmatix]

It's a bit confusing question. Surgery first is just what it sounds like, doing the surgery first instead of last. It shouldn't be a question about extractions or not, that is completely different treatment directions.

In general, doing the surgery first naturally give less accuracy. If you do surgery first you need to make assumptions of where the teeth will end up, which you don't need to do else since they're already there.

[GJ]

Surgery first is riskier. Surgery is already 1mm accuracy, which is a lot when it comes to teeth. 1mm is the difference between an open bite or closed bite, a crossbite or not, and edge to edge or not. I'm not sure what the accuracy of surgery first is, but say it's 2mm. That obviously increases the risk of every bite problem you can think of.

[Post bimax]

Extractions are the only option with pre-op orthodontics and are not necessary with surgery-first?

If you want to maximize orthodontic precision, you have to do pre and post op orthodontics.  Sometimes it's not necessary if the bite is already in a good spot.

[PloskoPlus]

Surgery first is riskier. Surgery is already 1mm accuracy, which is a lot when it comes to teeth. 1mm is the difference between an open bite or closed bite, a crossbite or not, and edge to edge or not. I'm not sure what the accuracy of surgery first is, but say it's 2mm. That obviously increases the risk of every bite problem you can think of.

1 mm only if it’s a top tier surgeon.

[kavan]

This question does not convey whether or not  surgeon B plans to pluck the pre-molars during the surgery.

[Dopesaint]

It's a bit confusing question. Surgery first is just what it sounds like, doing the surgery first instead of last. It shouldn't be a question about extractions or not, that is completely different treatment directions.

In general, doing the surgery first naturally give less accuracy. If you do surgery first you need to make assumptions of where the teeth will end up, which you don't need to do else since they're already there.

I forgot to add that both surgeons stated they can do surgery first accurately, as I am a mild case and mostly doing it for aesthetics. I also have had braces before.

Surgery first is riskier. Surgery is already 1mm accuracy, which is a lot when it comes to teeth. 1mm is the difference between an open bite or closed bite, a crossbite or not, and edge to edge or not. I'm not sure what the accuracy of surgery first is, but say it's 2mm. That obviously increases the risk of every bite problem you can think of.

I haven't found many articles mentioning it being riskier, of course, I don't deny that it may be and it could be a marketing tool since orthodontic treatment is much shorter with surgery first approach as stated here https://www.sciencedirect.com/science/article/pii/S0901502715002258

Extractions are the only option with pre-op orthodontics and are not necessary with surgery-first?

If you want to maximize orthodontic precision, you have to do pre and post op orthodontics.  Sometimes it's not necessary if the bite is already in a good spot.

I've had braces before so I do think my overbite is already in a good spot for DJS with CCW.

This question does not convey whether or not  surgeon B plans to pluck the pre-molars during the surgery.

Apologies, both surgeons offered surgery first approach in my consultation.

After surgeon A offered the surgery first option, I asked him if decompensation will give more projection and he stated yes but I would need to do the decompensation within pre orthodontics.

After surgeon B offered the surgery first option, I asked him the same question that I asked surgeon A. He stated whether I go with decompensation with pre orthodontics or surgery first option then orthodontics, in the end, the same end result will be achieved with him (both will require post-orthodontics). He did not say he would extract the premolars with the surgery first option, he would rather keep them.

Sorry if I am not explaining this correctly, all this is still fairly new to me.

[kavan]

Apologies, both surgeons offered surgery first approach in my consultation.

After surgeon A offered the surgery first option, I asked him if decompensation will give more projection and he stated yes but I would need to do the decompensation within pre orthodontics.

After surgeon B offered the surgery first option, I asked him the same question that I asked surgeon A. He stated whether I go with decompensation with pre orthodontics or surgery first option then orthodontics, in the end, the same end result will be achieved with him (both will require post-orthodontics). He did not say he would extract the premolars with the surgery first option, he would rather keep them.

Sorry if I am not explaining this correctly, all this is still fairly new to me.

OK. thanx for clarifying.

[Dogmatix]

I forgot to add that both surgeons stated they can do surgery first accurately, as I am a mild case and mostly doing it for aesthetics. I also have had braces before.

Well. In case everything looks well prepared, it won't be much decompensation needed anyway and you might as well do it. Regardless what they tell you, it will all come down to that having everything prepared before surgery give better prediction. It doesn't matter if you do it for aesthetics, if you displace the jaws you will also displace the bite and it's a small comfort knowing you had a good bite before surgery if you don't after. If you're talking about extractions it sounds like rather big orthodontic movements. It's mostly the surgeon who benefit from surgery first as they can sell you the surgery faster, the end result is better if it's done the conventional way.

[kavan]

Well, in terms of the end result being same/similar and having a situation where you don't need pre-molar extraction to either prepare for a surgery or having it done during the surgery, more likely than not, given you are class 2 (lower jaw recession), the decompensation pre-prep with braces, most likely would NOT be to your visual liking. That's because the decompensation phase to prep for a surgery (via lower pre-molar extraction) would buck out the upper teeth and push backwards the lower teeth which will give an over bite look. Basically, you'd be stuck looking worse for some time in preparation for a surgery to make you look better.

The TIME in braces is LESS with surgery first. Has to do with the fresh wound and blood flow with the jaw cuts helping the teeth to move into place faster.

You will need an ortho who works CLOSELY with the attending surgeon. Like you don't want a surgeon who's going to want to wipe his hands clean of you after the surgery and leave all up to the ortho. You want a surgeon who will entertain hearing you out if you have post surgery ortho issues where things don't line up as he had planned. In some cases, a revision might be on the table.

[Dopesaint]

Well, in terms of the end result being same/similar and having a situation where you don't need pre-molar extraction to either prepare for a surgery or having it done during the surgery, more likely than not, given you are class 2 (lower jaw recession), the decompensation pre-prep with braces, most likely would NOT be to your visual liking. That's because the decompensation phase to prep for a surgery (via lower pre-molar extraction) would buck out the upper teeth and push backwards the lower teeth which will give an over bite look. Basically, you'd be stuck looking worse for some time in preparation for a surgery to make you look better.

The TIME in braces is LESS with surgery first. Has to do with the fresh wound and blood flow with the jaw cuts helping the teeth to move into place faster.

You will need an ortho who works CLOSELY with the attending surgeon. Like you don't want a surgeon who's going to want to wipe his hands clean of you after the surgery and leave all up to the ortho. You want a surgeon who will entertain hearing you out if you have post surgery ortho issues where things don't line up as he had planned. In some cases, a revision might be on the table.

Thank you for your reply.

Would you say I am sacrificing greater movement of the jaws by doing surgery first approach with surgeon A or even with surgeon B?

What confuses me is that surgeon B states decompensation makes no difference when it comes to the end result, he stated with surgery first approach, once the surgery is complete, my incisors will be lined up like a slight underbite and then my ortho can fix them with post orthodontics to create a normal occlusion. Basically saying that the jaws will be moved in the same way and there isn't a greater movement with decompensation.

Is surgeon B wrong in this case or is it possible? If so I would just go with decompensation to optimize eventual aesthetics.

[PloskoPlus]

Surgeon B just wants your money. Unless you have serious crowding preop decompensation doesn’t take long.

[Dopesaint]

Surgeon B just wants your money. Unless you have serious crowding preop decompensation doesn’t take long.

I do have mild crowding, Surgeon A stated if I don’t do surgery first approach, then decompensation with pre orthodontics will take 6 months and I’ll be ready for surgery. Is that a reasonable time frame?

[PloskoPlus]

I do have mild crowding, Surgeon A stated if I don’t do surgery first approach, then decompensation with pre orthodontics will take 6 months and I’ll be ready for surgery. Is that a reasonable time frame?

If you have crowding it’s even more important to be conservative. You seem to be in a rush, but a bad surgery is worse than no surgery. It’s not like buying a dud car. It’s not “just money”. Nothing in your mouth is ever the same after surgery. So do it right the first time.

[kavan]

Well, I don't know if surgeon A was conveying to you that WITH pre-molar extraction and with braces before surgery you get 'more' advancement that way than you would get if you just got pre-surgery braces but with no pre molar extraction. So, I don't know what 'more' is in reference to when you asked 'A'. In reference to not including extraction in PRE-SURGICAL PREP or in reference to more advancement with pre surgical preparation than with surgery first.

I can't say if Surgeon B was 'wrong'. It could be that surgeon A might not have been clear on what question you were asking him.