Beyond Sequential Treatment: Surgery-First Orthognathic Approach with Canine Substitution for Comprehensive Skeletal and Esthetic Resolution of Lateral Incisor Agenesis: A Case Report
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Abstract
Abstract: The surgery-first approach (SFA) to orthognathic treatment has emerged as a compelling alternative to conventional protocols, offering immediate skeletal correction without prolonged presurgical orthodontics. A key biological advantage is the regional acceleratory phenomenon (RAP), a post-surgical response that accelerates orthodontic tooth movement and reduces overall treatment duration significantly. The present case involved a patient presenting with a concave facial profile, retrusive upper lip, reverse overjet and overbite of 3 mm, proclined maxillary incisors, retroclined mandibular incisors as dental compensation, Class I molar relationship, maxillary arch spacing, mild mandibular anterior crowding, and congenitally absent maxillary lateral incisors. This constellation of findings, combined with the patient's desire for early aesthetic improvement and the anticipated benefit of RAP-driven accelerated tooth movement, guided the decision toward SFA as the most appropriate patient-centred strategy. Le Fort I maxillary advancement was performed, followed by expedited postoperative orthodontics. Canine substitution addressed the congenitally missing lateral incisors and restored smile harmony. Treatment was completed in seven months, substantially shorter than conventional protocols. At the 24-month follow-up, Class I occlusion with ideal overjet and overbite was maintained, facial profile improvement remained stable, and functional outcomes were consistent. Keywords: Canine substitution; Class III malocclusion; Maxillary retrognathism; Orthognathic surgery; Surgery-first approach
1. Bichu YM, Alwafi A, Zou B, et al. Insights into concepts, protocols, and evidence of surgery-first orthognathic approach: the journey so far. Semin Orthod. 2022;28:247-257.
2. Borges TM, Sol I, de Castro Rodrigues CM, et al. Surgery-first approach in orthognathic surgery: considerations and clinical case report. Ann Maxillofac Surg. 2021;11:349-351.
3. Gandedkar NH, Chng CK, Tan W. Surgery-first orthognathic approach case series: salient features and guidelines. J Orthod Sci. 2016;5:35-42.
4. Datta R. When to substitute a missing upper lateral with a canine: a simplified approach. J Indian Orthod Soc. 2021;55(3):305-309.
5. Josefsson E, Hedmo C. Missing maxillary lateral incisors: a narrative review of treatment alternatives. Semin Orthod. 2025. Article in press. doi:10.1053/j.sodo.2025.09.007.
6. Bhattacharya P, Chandana AK, Bhandari R, et al. Case report on surgery-first approach. Ann Maxillofac Surg. 2021;11:352-355.
7. Liou EJ, Chen PH, Wang YC, et al. Surgery-first accelerated orthognathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg. 2011;69:771-780.
8. Choi DS, Garagiola U, Kim SG. Current status of the surgery-first approach (part I): concepts and orthodontic protocols. Maxillofac Plast Reconstr Surg. 2019;41:10.
9. Ko EW, Hsu SS, Hsieh HY, et al. Comparison of progressive cephalometric changes and postsurgical stability of skeletal Class III correction with and without presurgical orthodontic treatment. J Oral Maxillofac Surg. 2011;69:1469-1477.
10. Huang CS, Chen YR. Orthodontic principles and guidelines for the surgery-first approach to orthognathic surgery. Int J Oral Maxillofac Surg. 2015;44:1457-1462.
2. Borges TM, Sol I, de Castro Rodrigues CM, et al. Surgery-first approach in orthognathic surgery: considerations and clinical case report. Ann Maxillofac Surg. 2021;11:349-351.
3. Gandedkar NH, Chng CK, Tan W. Surgery-first orthognathic approach case series: salient features and guidelines. J Orthod Sci. 2016;5:35-42.
4. Datta R. When to substitute a missing upper lateral with a canine: a simplified approach. J Indian Orthod Soc. 2021;55(3):305-309.
5. Josefsson E, Hedmo C. Missing maxillary lateral incisors: a narrative review of treatment alternatives. Semin Orthod. 2025. Article in press. doi:10.1053/j.sodo.2025.09.007.
6. Bhattacharya P, Chandana AK, Bhandari R, et al. Case report on surgery-first approach. Ann Maxillofac Surg. 2021;11:352-355.
7. Liou EJ, Chen PH, Wang YC, et al. Surgery-first accelerated orthognathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg. 2011;69:771-780.
8. Choi DS, Garagiola U, Kim SG. Current status of the surgery-first approach (part I): concepts and orthodontic protocols. Maxillofac Plast Reconstr Surg. 2019;41:10.
9. Ko EW, Hsu SS, Hsieh HY, et al. Comparison of progressive cephalometric changes and postsurgical stability of skeletal Class III correction with and without presurgical orthodontic treatment. J Oral Maxillofac Surg. 2011;69:1469-1477.
10. Huang CS, Chen YR. Orthodontic principles and guidelines for the surgery-first approach to orthognathic surgery. Int J Oral Maxillofac Surg. 2015;44:1457-1462.
| Files | ||
| Issue | Vol 13, No 3 (Summer 2026) | |
| Section | Case Report(s) | |
| Keywords | ||
| Canine substitution; Class III malocclusion; Maxillary retrognathism; Orthognathic surgery; Surgery-first approach | ||
| Rights and permissions | |
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Viswanathan R, Gupta A, Sharma R, Kumar D. Beyond Sequential Treatment: Surgery-First Orthognathic Approach with Canine Substitution for Comprehensive Skeletal and Esthetic Resolution of Lateral Incisor Agenesis: A Case Report. J Craniomaxillofac Res. 2026;13(3):411-417.
