Surgery first orthognathic approach: a case series of 3D planning and pre-bent plates in patients with single- and double-jaw surgeries

Background: In comparison to the traditional approach, the surgery-first orthognathic approach (SFOA) offers decreased treatment times and immediate esthetic and functional results. The method of preparing a patient for orthognathic surgery has also been revolutionized by the adoption of 3D planning. Virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) enables preoperative fabrication of individualized drilling guide templates, occlusal splints, and pre-bent titanium plates, which have shown to decrease surgical time and improve operative accuracy. Orthognathic surgery has undergone a slow and steady improvement, which over time has proven to be highly accurate and then adopted as the minimum standard of care. The same can be said for how these cases are planned, with 3D planning today being accepted as a highly accurate and reproducible step undertaken prior to surgery. However, the appropriateness and feasibility of widespread adoption of pre-bent plates for all orthognathic cases is still in question. Case Description: In this case series report, we present 4 patients treated with SFOA, where preoperatively, three of the patients had class III malocclusion, and one had class II malocclusion. For all cases, drilling guide templates, printed occlusal splints, and pre-bent titanium plates created via VSP were used intraoperatively. While all 4 patients underwent Le Fort I osteotomies, 2 patients also underwent bilateral sagittal split osteotomies (BSSO), and 1 patient also underwent bilateral coronoidectomy, bilateral joint replacements and genioplasty. All cases were completed with no intraoperative complications. Stable long term follow-up results were achieved using SFOA, which were comparable to a traditional orthognathic approach. Furthermore, in Le Fort I osteotomies, pre-bent plates reduced operative time and provided a higher degree of accuracy. However, such results were not replicated in BSSO cases. Across all early SFOA BSSO cases at our institution, nearly one-third of the pre-bent plates were not sufficiently long enough to allow adequate fixation and traditional methods of bending plates intraoperatively were utilized. Other modifications to the cutting guides and pre-bent plates were also made to overcome the discrepancies. Recurrence rates did not differ between pre-bent plates and plates fashioned intraoperatively. Conclusions: Our experience with VSP revealed an associated learning curve dependent on the experience of both the surgeon and software technician. Despite this learning curve and the insufficiencies of the pre-bent plates in BSSO cases, overall, our experience incorporating 3D planning and pre-bent plates in SFOA cases demonstrated decreased operative time, increased operative accuracy, and comparable long term follow-up results compared to traditional approaches.