Orthognathic surgery for the Invisalign

patient
Daniel I. Taub, DDS, MD, and Victoria Palermo, DDS, MD

Orthognathic surgery has continued to evolve, with increasing utilization of

digital imaging and software to facilitate both the pre-surgical orthodontics
via Invisalign therapy, as well as virtual surgical planning (VSP). While
offering the advantage of comprehensive and patient-specific analysis, these
novel technologies have also inadvertently introduced challenges in execu-
tion of the surgical plan, causing select providers to question their utility in
surgical cases. Through elimination of traditional orthodontic appliances,
which have historically served to provide anchoring hardware for intra-
operative splint stabilization, patients managed pre-surgically with Invisalign
necessitate modification of the operative techniques. Here we provide an
overview of several alternative methods to facilitate maxillomandibular
repositioning and stabilization, including utilization of Erich arch bars, Ivy
loops, intermaxillary fixation (IMF) screws and hybrid arch bar systems.
Application of these techniques in orthognathic surgery, expanded and adapted
from arena of maxillofacial trauma, allows optimization of scope of indications
for the Invisalign system and may increase case acceptance for surgical patients
seeking esthetic and minimally invasive orthodontic options. (Semin Orthod
2017; 23:99–102.) & 2017 Elsevier Inc. All rights reserved.

T reatment of malocclusion secondary to

skeletal discrepancy should include surgical
correction. Orthognathic surgical correction of
osteotomy, are used. As both techniques achieve
a three-dimensional repositioning of the skeletal
units, surgical splints are indispensable aids in
the maxillofacial complex is technique sensitive the process. Typically, in the process of surgical
and requires meticulous planning. There are a correction of the pitch, yaw and cant of the
limited number of fundamental surgical techni- skeletal units, the surgeon must rely upon pre-
ques to reposition the maxillomandibular com- fabricated surgical splints. The splint is the
plex in three dimensions. Repositioning of the instrument to position the occlusion of the
maxilla and correction of a midface projection is opposing dental arches and it also stabilizes the
usually achieved with the use of a LeFort I,II or III skeletal units at the new locus. While rigid
osteotomy. This can be completed with or internal fixation with bone plates and screws
without segmentation to achieve transverse provides long-term stability and allows quick
correction or segmental alignment. Similarly, return to function,1–3 the splint-aided intra-
repositioning of the mandible is accomplished operative intermaxillary fixation within the
via mandibular ramus osteotomy. Most fre- occlusal splint is the mechanism that guides and
quently, the technique of sagittal split ramus determines the position in which rigid fixation
osteotomy is used, but also when indicated, var- will be accomplished.4,5
iations of the technique, including vertical ramus Pre-operative analysis and planning is done
based on the clinical information collected by the
Department of Oral and Maxillofacial Surgery, Thomas Jefferson surgeon. These are similar to what the ortho-
University, Philadelphia, PA. dontists collect: clinical photos, cephalometric
Address correspondence to Daniel I. Taub, DDS, MD, Department radiographs, dental models, bite registration,
of Oral and Maxillofacial Surgery, Thomas Jefferson University, 909 and face bow transfer. This data, in conjunction
Walnut St, COB, 3rd Floor, Philadelphia, PA 19107.
E-mail: Daniel.Taub@jefferson.edu
with ex-vivo model surgery on a semi-adjustable
articulator, allows the surgeon to assess the fea-
& 2017 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 sibility of required surgical intervention and to
http://dx.doi.org/10.1053/j.sodo.2016.10.008 position the maxilla and/or mandible in an ideal

Seminars in Orthodontics, Vol 23, No 1, 2017: pp 99–102 99

100 Taub and Palermo

relationship.4–6 This process is a simulation of the to providing a perhaps more consistent

correction for both the occlusal deformity and and comprehensive approach to treatment of
skeletal discrepancy. It is the blueprint for in-vivo complex craniofacial disorders.10 The VSP differs
intervention. It cannot be overemphasized that from traditional model surgery in that, it makes
the model surgery performed on the articulator use of stone models in conjunction with
reflects the utmost precision and accuracy of maxillofacial CT data to generate a virtual
meticulous measurements and attention to detail 3-dimensional model combining max-
to simulate surgical movements. In order to illomandibular skeletal anatomy with dentoal-
enable the transfer of information from the veolar form. This constructed virtual model
mounted dental casts to the operating field, an allows for manipulation and simulation of skel-
interocclusal splint is fabricated by the surgeon. etal and occlusal changes and movements. The
It serves as the guide to position the free osteo- resulting surgical plan takes into account not
tomized segment with relation to a stable skeletal only the relationship of the dental arches to each
point. Furthermore, in select cases, a stabilizing other, but also anticipated position of the bony
splint may be indicated in the post-operative segments, revealing potential challenges or
phase as well. It facilitates predictable bony interferences. Once the virtual simulation is
healing positions. For example, cases where the completed, stereolithographic splints are fabricated
maxilla or mandible have been expanded or for use during surgery, theoretically eliminating
narrowed through a segmental approach, or introduction of error due to multistep nature of
cases where stable occlusion post-operatively conventional model surgery. Despite a novel
cannot be achieved due to missing dentition or method of surgical planning and splint fabrication,
severe tooth wear are critically dependent on the intermaxillary fixation and stabilization of the splint
splint. Secure fixation of the interocclusal splint remains key in achieving predicted outcomes.
or stabilization of the maxillomandibular com- Overall, the excellence of pre-surgical ortho-
plex in the anticipated interdigitated position is dontics is essential for the success of orthog-
key to obtaining predicted surgical outcomes. nathic surgery, just as it is to post-surgical
More recently, with the advent and increased repositioning of teeth. The orthodontist must
availability of computer tomography (CT) therefore be well versed in the surgical techni-
imaging and technology that allows sophisticated ques. Such knowledge makes the orthodontist
manipulation of the generated data, virtual sur- understand and appreciate the concessions that
gical planning (VSP) and computer assisted may be necessary secondary to the use of Invis-
design/manufacturing (CAD/CAM) of surgical align therapy compared to traditional ortho-
splints has gained increased acceptance within dontics. These two orthodontic appliances are
craniofacial surgery.7,8 This has been further vastly different for the surgeon who is managing
reinforced with increasing availability of data the surgery, the healing, and the long-term sta-
supporting the accuracy of VSP,9 in addition bility of the correction.

Figure 1. (A) Occlusal scheme established with Invisalign treatment prior to maxillomandibular advancement for
correction of skeletal discrepancy. (B) Erich arch bars in place, providing anchorage for maxillomandibular
fixation. Note preservation of gingival architecture and unobstructed access for surgical incision 5 mm apical to the
mucogingival junction.
 Orthognathic surgery 101

Figure 2. (A) Occlusal scheme established with Invisalign treatment prior to maxillomandibular advancement for
correction of skeletal discrepancy. (B) Intermaxillary fixation screws in place providing four points of
maxillomandibular fixation, distributed bilaterally. (C) Four screws on each side provide two points of
maxillomandibular fixation, one more anterior in the canine and first premolar region and one more posterior
in the first and second molar region.

Traditional orthodontic therapy with ortho- Arch bars are applied to the dentition in both
dontic wires provides opportunity for application of the maxillary and mandibular arches and secured
surgical lugs or Kobayashi style ligature wires. by circumdental wires; with inter-arch wires sub-
They are most dependable and indispensable sequently used to establish occlusion (Fig. 1). The
in their utility and facilitate intraoperative max- draw backs of the arch bar technique include
illomandibular fixation into occlusion with oppos- greatly increased operative time and consequent
ing arch, as well as pre-fabricated intermediate or patient exposure to extended anesthesia, trauma to
final surgical splint. The Invisalign appliance has the periodontium, compromised oral hygiene, as
eliminated such hardware; an additional challenge well as increased risk of penetrating trauma to the
is now created for the surgical phase. These chal- surgeon. Interdental fixation with eyelet or Ivy
lenges, however, can be easily circumvented with loops also relies on wires placed circumdentally,
appropriate surgical planning and application of subsequently wired together to create maxillo-
techniques for maxillomandibular fixation com- mandibular fixation. An advantage of this
monly used in the setting of facial trauma. Thus, in technique is somewhat improved operating time
the absence of lugs of Kobayashi ties, intermaxillary due to decreased number of circumdental wires
fixation can be achieved by interdental wire fixation necessary to establish stable occlusion and
via Ivy loops, application of Erich arch bars,11 the improved ease or removal following the period
use of bonded brackets or buttons, and the use of of maxillomandibular fixation.
intermaxillary fixation screws, which may be Recent development of intermaxillary fixation
considered under the category of temporary (IMF) screws, starting with initial description of
skeletal anchorage devices (TADs). their use by Arthur and Berardo in 1989,12 provided

Figure 3. Examples of commercially available bone supported arch bars. (A) SmartLock Hybrid MMF
manufactured by Stryker Craniomaxillofacial and (B) MatrixWave MMF manufactured by DePuy Synthes.
102 Taub and Palermo

an additional alternative to conventional arch bar References

application. They decrease operating room time, 1. Van Sickles JE, Richardson DA. Stability of orthognathic
facilitate easier placement, and decrease the risk of surgery: a review of rigid fixation. Br J Oral Maxillofac Surg.
damage to the periodontal apparatus. An additional 1996;34:279–285.
advantage, which is of upmost importants in elective 2. Michelet FX, Deymes J, Dessus B. Osteosynthesis with
miniaturized screwed plates in maxillofacial surgery.
cases, such as orthognathic surgery, is improved J Maxillofac Surg. 1973;1:79.
acceptance by patients.13–15 Screws are positioned 3. Proffit William R, White Raymond P, Sarver David M.
in a bicortical fashion between the roots of the teeth Contemporary Treatment of Dentofacial Deformity. St. Louis:
at the mucogingival junction or in attached tissue. Mosby; 2002.
In our experience, typically eight IMF screws are 4. Fonseca Raymond J, Marciani Robert D, Turvey Timothy.
Oral and Maxillofacial Surgery: 3-Volume Set. 2nd ed. Volume
placed to provide a total of four points of max-
III. St. Louis: Saunders; 2008.
illomandibular fixation distributed bilaterally 5. Posnick Jeffrey C. Orthognathic Surgery: Principles and Practice.
(Fig. 2A and B). As all treatment modalities have 1st ed. Volume I. St, Louis: Elsevier Saunders; 2013
limitations and risks of distinct complications, IMF 6. Erickson K, Bell WH, Goldsmith D. Analytical Model
screws are not an exception and may cause root Surgery. Modern Practice in Orthognathic and Reconstructive
injury,16–18 present a risk of aspiration, screw loos- Surgery. Philadelphis: Saunders 1992; 154–216.
7. Levine JP, Patel A, Saadeh PB, et al. Computer-aided
ening, with compromise in the maxillomandibular design and manufacturing in craniomaxillofacial surgery:
fixation, and screw shearing. Recent reports of the new state of the art. J Craniofac Surg. 2012;23:
clinical studies have shown that in comparison of 288–293.
self-drilling and self-tapping screws, the self-drilling 8. Hammoudeh JA, Howell LK, Boutros S, Scott MA, Urata
screws presented an overall better safety profile.18 MM. Current status of surgical planning for orthognathic
surgery: traditional methods versus 3D surgical planning.
Furthermore, recent development of bone
Plast Reconstr Surg Glob Open. 2015;3(2):e307.
supported arch bars provides a hybrid between 9. Gelesko S, Markiewicz MR, Weimer K, et al. Computer-
circumadentally retained Erich Arch bars and aided orthognathic surgery. Atlas Oral Maxillofac Surg Clin
fixation screws, seeking to combine the North Am. 2012;20:107–118.
advantages of both. Some examples of such 10. Gateno J, Xia JJ, Teichgraeber JF, et al. Clinical feasibility
of computer-aided surgical simulation (CASS) in the
appliances include the SmartLock Hybrid MMF
treatment of complex cranio-maxillofacial deformities.
(Fig. 3A), manufactured by Stryker Cranio- J Oral Maxillofac Surg. 2007;65:728–734.
maxillofacial, as well as the MatrixWave MMF 11. Mukerji R, Mkerji G, McGurk M. Mandibular fractues:
System, manufactured by DePuy Synthes (Fig. 3B). historical perspective. Br J Oral Maxillofac Surg. 2006;
Orthodontic therapy with clear aligners has 44:222.
shifted the paradigm in both the orthodontic 12. Arthur G, Berardo N. A simplified technique of max-
illomandibular fixation. J Oral Maxillofac Surg. 1989;
management of malocclusion and the intraoperative 47:1234.
needs of the orthognathic surgery patient during 13. Nandini GD, Balakrishna R, Rao J. Self tapping screws v/s
maxillomandibular manipulation. The evolution in Erich arch bar for inter maxillary fixation: a comparative
software technology, specifically with manipulation clinical study in the treatment if mandibular fractures.
of data to create three-dimensional models, provides J Maxillofac Oral Surg. 2011;10:127.
14. Imazawa T, Komuro Y, Inoue M, et al. Mandibular
multidisciplinary teams with additional opportunities
fractures treated with maxillomandibular fixation screws
to refine treatment plans through combination of (MMFS method). J Craniofac Surg. 2006;17:544.
orthodontic treatment planning and virtual surgical 15. Ueki K, Marukawa K, Shimada M, et al. The use
planning. The concurrent elimination of conven- of intermaxillary fixation screw for mandibular set-
tional orthodontic hardware, albeit challenging at back surgery. J Oral Maxillofac Surg. 2007;65(8):
first glance due to compromised surface for inter- 1562–1568.
16. Fabbroni I, Aabed A, Mizen K, et al. Transalveolar screws
maxillary fixation, fuels ingenuity in bringing the and the incidence of dental damage: a prospective study.
concepts of maxillomandibular fixation traditionally Int J Oral Maxillofac Surg. 2004;33:442.
used in trauma into the arena of elective orthog- 17. Schulte-Geers M, Kater W, Seeberger R. Root trauma and
nathic surgery. Here we presented alternative tooth loss through the application of pre-drilled trans-
options of inter-arch fixation that can be utilized gingival fixation screws. J Craniomaxillofac Surg. 2012;
40:214.
in the setting of maxillary and/or mandibular
18. Bins A, Oomens MAE, Boffano P, et al. Is there enough
osteotomies in the setting of Invisalign therapy; in evidence to regularly apply bone screws for intermaxillary
the process, exploring opportunities to provide fixation in mandibular fractures? J Oral Maxillofac Surg.
expanded scope of exceptional patient care. 2015;73(10):1963–1969.