Surgery-First or Orthodontics-First: An Orthodontic “To Be or Not to Be”—A Narrative Review ()
1. Introduction
Surgery-first or orthodontics first…a dilemma that echoes like an orthodontic “to be or not to be”. While we may think that the surgery-first approach is a modern treatment strategy, it’s actually a revisitation of historical orthognathic practices. Over time, orthodontic innovations have facilitated precise three-dimensional repositioning of teeth, which has made orthognathic surgery rely on orthodontics to better the predictability of treatment outcomes [1]. Conventionally, orthodontic cases involving orthognathic surgery follow the classical workflow of first orthodontic incisor decompensation, second orthognathic surgery and finally post-surgical orthodontic treatment. This treatment workflow has proven to be effective [2]; however, the cost would be the inevitable worsening of the patient’s profile due to the decompensation phase [3]. As a result, patients’ psychological health worsens as well, leading us to explore other techniques to prevent this.
A historical perspective reveals that in 1897, Vilray Papin Blair performed the first bilateral ostectomy of mandibular body using an extraoral approach [4]. And after publication of his case, Angle commented that a V-section should have been used, as well as cast gold splints for post-operative fixation. Noting the first communications between surgeons and orthodontists.
By 1908, the collaboration between orthognathic surgeons and orthodontists gained official recognition. This milestone was marked by Max Ballin’s presentation to the American Board of Orthodontists. Dr. Pullen, the board’s chairman, emphasized the significance of interdisciplinary cooperation, stating:
“It is the first time in the history of the American Society of Orthodontists that such a clinic has been given, and we are glad to have such a record as the work which has been done so successfully for its kind as shown this morning... Now we, as orthodontists, do not pretend to tell the surgeon anything that is new to him, but there is no doubt that the medical profession can profit by suggestions from the dental profession, and vice versa, and by this cooperation, we will further and better our practices and benefit humanity thereby.” [1].
Despite these historical advances, conventional presurgical orthodontic workflows have a notable drawback: worsening of the patient’s appearance during the presurgical phase, coupled with the extended overall treatment duration [5]. This limitation has prompted a re-evaluation of older approaches, emphasizing the correction of the patient’s aesthetics from the outset.
The first documented conceptual suggestions of pre-orthodontic surgery started in 1985 by Skaggs, followed by Behrman in 1988 and Brachvogel et al. in 1991. It was not until 2009 that these ideas were clinically put into practice by Nagasaka et al., publishing the collaborative approach they took between orthodontists and surgeons [6].
This article aims to provide a review of the surgery-first approach (SFA) in orthognathic surgery by going back to the basics of indications, limitations and potential risks by discussing the implications of advanced 3D planning technologies in improving treatment predictability. This is designed for clinicians to evaluate SFA’s applicability for patient-centred outcomes.
2. Methods
This narrative review was conducted following the PICO (Population, Intervention, Comparison, Outcome) framework, including patients with skeletal Class II or III malocclusions undergoing orthognathic surgery (Population), comparing the Surgery-First Approach (Intervention) with the conventional Orthodontics-First Approach (Comparison), and evaluating treatment duration, stability, esthetic outcomes, and patient satisfaction (Outcomes). An electronic search of PubMed and Scopus was performed without time restriction until January 2025, using the keywords: (“orthognathic surgery” OR “jaw surgery”) AND (“orthodontics” OR “orthodontic treatment”) AND (“surgery-first approach” OR “early orthognathic approach” OR “SFA”) OR (“orthognathic surgery” OR “jaw surgery”) AND (“orthodontics” OR “orthodontic treatment”) AND (“conventional orthognathic approach” OR “orthodontics-first approach”), with the equation adapted to each database syntax.
Only peer-reviewed articles published in English were considered, with no restrictions on study design or geographic origin to provide a comprehensive overview typical of a narrative review. Studies were excluded if they reported on syndromic cases or rare/exceptional cases unlikely to reflect general clinical practice.
A total of 387 records were initially identified. After removing duplicates, 237 articles were screened. Based on title and abstract reading, 66 articles were selected for further evaluation. Following full-text reading and application of inclusion and exclusion criteria, 17 articles were finally included in this review.
As this is a narrative review, the methodology outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was not applied and methodological quality assessment of included articles was not undertaken.
3. Results
3.1. Surgery-First Approach Proposed Protocol
What sets the SFA apart from the conventional approach is that there is no need for pre-surgical orthodontics. This means that ideally the direction of dental compensation during surgery must be consistent with the adjustments to be made in the post-surgical orthodontic phase [1]. The malocclusion correction is only addressed in the post-surgical orthodontic phase [7]. However, in some cases, minor adjustments may be needed for 1 to 2 months to resolve occlusal interferences [1]. Therefore, it is proposed to opt for SFA for patients with mild to moderate dental crowding, generally defined as less than 4 mm of tooth size–arch length discrepancy per arch, and well-coordinated dental arches, meaning minimal transverse discrepancy (≤2 mm), stable molar relationship, and compatible occlusal planes [8].
First, before proceeding with surgery, a simulation is performed using dental models. The maxilla and mandible are positioned to establish correct molar relationships, with a positive overbite. The importance of simulation resides in enabling the clinician to preview the results. This makes it possible to efficiently plan for the post-surgical orthodontic phase.
In the conventional approach, incisor decompensation serves as a key guide for predicting the final occlusion, whereas the molar relationship acts as the primary guide in the SFA.
For non-extraction cases or cases involving the extraction of bimaxillary first premolars, the molar relationship is adjusted to a Class I relationship. In patients with extracted mandibular first premolars, the molar relationship is set to Class III, while in patients with extracted maxillary first premolars, it is adjusted to Class II.
To ensure proper fixation during surgery, different techniques may be used involving the placement of a surgical arch bar, anchor screws, light round or rectangular wires (with or without anchor screws or plates), or conventional passive rectangular wires with surgical hooks (with or without anchorage screws) [9].
Following the establishment of the molar relationship, the overjet is assessed. Orthodontic treatment can begin 1 week to 1 month postoperatively to take advantage of the accelerated orthodontic tooth movement phenomenon [6]. Liou et al. established specific guidelines for certain clinical situations, summarized in Table 1.
3.2. Surgery-First versus Conventional: Which Approach Wins?
Having explored the concept of the surgery-first approach and its proposed protocol, one critical question arises for every clinician: why change a therapeutic approach that has proven effective? Is it truly worthwhile to navigate a learning curve, face new challenges, and adapt after years of honing and perfecting established skills?
In the conventional orthognathic surgical approach, the presurgical dental decompensation phase is time-consuming and negatively impacts patients’ appearance. This negatively affects patients’ quality of life and motivation to pursue the treatment further [10]. Therefore, SFA enables practitioners to provide patient-centred care, aimed at addressing the patient’s primary chief complaint while minimizing disruption to their social and daily life [1] [7]. The immediate
Table 1. Specific recommendations by Liou et al. (2011) [11].
Class II |
Moderate to deep mandibular Curve of Spee with proclined lower incisors in Class II mandibular retrognathia |
- Anterior segmental osteotomy for leveling, intrusion, and mandibular advancement. - Edge-to-edge mandibular advancement with postoperative orthodontic intrusion for occlusal contact and chin projection. |
Class III |
Proclined incisive |
- Maxillary first premolar extraction combined with anterior segmental osteotomy. - Clockwise mandibular rotation with Le Fort I osteotomy to correct upper incisor inclination. |
Moderately retroclined incisors with crowded lower anterior incisors |
Set up a Class I molar relationship with excessive incisor overjet, followed by postoperative alignment of lower incisors to achieve normal overjet. |
Severely retroclined incisors with crowded lower anterior incisors |
Extraction of lower first premolars and anterior segmental osteotomy, with Class III molar relationship and excessive incisor overjet, followed by postoperative alignment of lower incisors for normal overjet. |
Moderate to deep mandibular Curve of Spee |
Level the spee curve preoperatively or surgically with anterior segmental osteotomy to prevent upward and forward mandibular rotation. |
Transverse coordination |
Wide maxilla with a transverse discrepancy exceeding one molar width on each side |
Surgical coordination with a 3-piece Le Fort I osteotomy. |
Wide maxilla with a transverse discrepancy less than one molar width on each side |
Coordination by postoperative orthodontic tooth movement. |
Narrow maxilla |
Surgically assisted rapid palatal expansion. |
improvement of patients’ appearance is a fundamental advantage of SFA, Yang L et al. consider the impact on the patient’s quality of life may increase patients’ confidence to undergo treatment [10].
SFA is mainly praised for its reduced treatment time, which can be attributed to the post-surgical dental decompensation, aligns with the gradual adaptation of teeth and muscles to the new skeletal structures. This dynamic, combined with the normalization of surrounding tissues, promotes and facilitates subsequent orthodontic movements [7] [9]. It is also believed that the Regional Acceleratory Phenomenon (RAP), maximized after surgery, is a key factor in shorter orthodontic treatment times. RAP corresponds to a tissue reaction induced by a noxious stimulus, which stimulates the healing capacity of affected tissues through increased blood flow and localized cellular activity through bone turnover driven by surgery, which facilitates the progression of orthodontic corrections [1] [7] [12]. Regarding the shortened treatment time, there is ongoing debate. A review by Mirhashemi et al. reported that the mean overall treatment duration of treatment for SFA was 18.39 months compared to 23.34 months for the conventional approach [6]. However, although the presurgical phase is shorter in SFA, the post-surgical orthodontic phase is longer [10]. All in all, the treatment duration may vary depending on the clinical case, particularly in cases involving tooth extractions, which significantly extend the timeline. Mirhashemi et al.’s review revealed that in extraction cases, there was no significant difference in treatment duration between SFA (25.114 months) and the conventional approach (25.7 months) [6]. Consequently, SFA is more suitable for non-extraction cases to achieve optimal time efficiency.
One critical factor influencing clinicians’ decision-making is postoperative stability, which remains a key point of controversy regarding the surgery-first approach. A meta-analysis by Hongpu Wei et al. found no significant difference in maxillary relapse between the SFA group and the conventional approach [13]. However, the relapse of the mandible was higher in the SFA group, as the mandible tends to rotate counterclockwise [13]. Consequently, it is well-established that the conventional approach generally provides greater postoperative stability than SFA. However, it has been suggested that the method of fixation and the type of surgery may affect stability in SFA. Studies have recommended the use of anchor plates to improve postoperative stability in use of class III elastics and prevent forward movement of the jaw. Recent studies, however, indicate that SFA can achieve skeletal stability comparable to conventional approach when appropriate protocols are applied. Li et al. (2024) reported no significant differences in linear or angular deviations between SFA with clear aligners and the orthodontic-first approach (OFA), except for a minor difference in maxillary yaw (p = 0.005), with a significantly reduced overall treatment duration [14]. Similarly, Mansour et al. (2023) observed good postoperative stability with SFA, particularly at the maxilla, with only limited mandibular relapse (forward shift of 2.5 mm and vertical or transverse changes of 1 - 2 mm) [15]. Saghafi et al. (2025) also found no significant difference in maxillary stability between SFA and conventional approach following Le Fort I advancement, with minimal posterior relapse and no correlation with immediate occlusal quality. Collectively, these findings suggest that, when properly executed, SFA can provide predictable skeletal stability while reducing overall treatment time [16]. Table 2 provides a comparative summary of the quantitative findings reported in recent studies on the surgery-first approach, highlighting treatment duration, maxillary and mandibular relapse, and overall skeletal stability.
It should be noted, nevertheless, that the quality of the included studies was not formally assessed, which limits the strength of these conclusions and indicates that the findings should be interpreted with caution.
Table 2. Comparative summary of quantitative outcomes across key surgery-first approach studies.
Evaluated Aspect |
Key Metrics |
Implication |
Mean Treatment Time |
- Li et al., RCT reported: SFA = 18.0 ± 2.5 months, OFA = 22.8 ± 3.6 months ≈ 4 - 5 months shorter for SFA [14]. - Other studies [3] [15] [16] qualitatively confirmed a notable reduction in total treatment duration with the surgery-first approach. |
The SFA shortens overall treatment time by roughly 20% - 25% compared with the conventional orthodontics-first sequence. |
Relapse / Postsurgical Stability |
- Wei et al., 2018 (meta-analysis, 498 patients): pooled horizontal relapse 1.50 mm greater in SFA (p < 0.00001) [13]. - Saghafi et al., 2025: posterior maxillary relapse < 1 mm at 6 months, no significant difference between SFA and OFA [16]. - Mansour et al., 2023: mean relapse maxilla ≈ 0.7 mm, mandible ≈ 2.5 ± 2.0 mm (largest sagittal change) [15]. - Jeong et al., 2017: long-term (mean 74 months) follow-up showed no significant difference in anteroposterior stability between SFA and OFA [3]. |
Overall, SFA shows slightly higher relapse (≈1 - 2 mm)—mainly mandibular—but differences are small and rarely clinically relevant. |
Type/ Location of Relapse |
- Relapse most often occurs at the mandible (counter-clockwise rotation) [13] [15]. - Maxilla remains highly stable (relapse < 1 mm) [13] [15] [16]. |
Maxillary stability is good; mandibular relapse is mild and manageable when fixation and occlusion are well controlled. |
Additional Quantitative Advantages |
- Immediate aesthetic improvement and occlusal correction at surgery [14]. - No pre-surgical facial worsening (contrary to conventional approach) [16]. - Regional Acceleratory Phenomenon (RAP) enhances post-surgical tooth movement and may reduce orthodontic duration [16]. |
Immediate facial improvement, shorter overall treatment, and efficient postoperative tooth movement make SFA a clinically appealing option. |
Beyond esthetic improvement and skeletal stability, functional outcomes also represent a key dimension of success in the surgery-first approach. Several studies have reported that SFA can lead to early normalization of occlusal function, improved masticatory efficiency, and enhanced airway dimensions due to immediate skeletal correction[7] [10]. Nevertheless, these benefits depend largely on precise postoperative orthodontic coordination to ensure a harmonious occlusion and muscular adaptation to the new skeletal framework.
4. Conclusion
Deciding whether to opt for the surgery-first approach or the conventional one is not an easy decision. Beyond the clinician’s preference, mastering case selection is key. While SFA prioritizes treatment time reduction and patients’ aesthetic repercussions, it is not without limitations, such as the potential for increased post-operative instability. It might also not be the ideal approach for complex skeletal discrepancies or in extraction cases. This is why orthodontists must carefully weigh the benefits and drawbacks of each technique, with an emphasis on patient-centered care. Better results may be obtained as advancements in surgical 3D planning and techniques continue.
Conflicts of Interest
The authors declare no conflicts of interest.