Does Mandible-First Sequencing Increase Maxillary Surgical Accuracy in Bimaxillary Procedures?

Document Type


Publication Date


Publication Title

Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons


PURPOSE: In bimaxillary procedures, it is important to know how the chosen sequence affects the surgical outcome. The purpose of this study was to explore whether the theoretical advantages of using the mandible-first procedure were supported by clinical data.

MATERIALS AND METHODS: The authors performed a retrospective investigation on a cohort compiled from 3 published retrospective studies. The sample was composed of patients treated at the Radboud University Nijmegen Medical Centre (Nijmegen, the Netherlands) from 2010 to 2014 and the Odense University Hospital (Odense, Denmark) from 2011 to 2015. The inclusion criterion was bimaxillary surgery without maxillary segmentation. The exclusion criterion was lack of a virtual surgical plan. The primary outcome variable was surgical accuracy, defined as the mean difference between the obtained outcome and the virtual surgical plan. The primary predictor variable was the comparison between mandible-first and maxilla-first sequencing. Secondary predictors were inferior maxillary repositioning and counterclockwise (CCW) rotation. The confounding variable was the virtually planned reposition. Results were analyzed by mixed-model regression encompassing all variables, followed by a detailed analysis of positive results using 2-sample t tests.

RESULTS: Overall, 145 patients were included for analysis (98 women; mean age, 28 years). Operating on the mandible first notably influenced maxillary positioning and placed the maxilla 1.5 mm posterior and with 1.4° of CCW rotation compared with virtual surgical planning. The interaction of surgical sequence with maxillary rotation showed similar surgical accuracy between maxilla-first surgery with clockwise rotation and mandible-first surgery with CCW rotation. Inferior maxillary repositioning resulted in the maxilla being placed 1.7 mm (maxilla-first sequence) and 2.0 mm (mandible-first sequence) posterior to the planned position.

CONCLUSION: Surgical accuracy was considerably influenced by sequencing in bimaxillary procedures. It remains important to know how the chosen sequence affects the surgical outcome so that the virtual surgical plan can be adjusted accordingly.