Clinician Consensus on Patient Suitability for a 'Surgery First' approach to Orthognathic Treatment

Objectives: To determine and reach consensus on which dentoskeletal features influence clinicians’ judgement of an individual’s suitability for a 'Surgery First' approach (SFA) to orthognathic treatment.
Design: Cross sectional, mixed methods consensus study.
Setting and Participants: Two UK based workshops (2025) involving seventeen consultant orthodontists and maxillofacial surgeons experienced in orthognathic care.
Materials and Methods: In Workshop 1, participants independently assessed 70 anonymised orthognathic cases using standardised pre treatment records. Each case was scored for orthognathic and SFA suitability, alongside the influence of eight dentoskeletal features. Quantitative analysis included descriptive statistics, inter and intra rater agreement. Free text responses explored clinical reasoning. Findings informed a second, professionally-facilitated virtual consensus workshop using structured discussions and anonymous ranking to prioritise key features.
Results: A total of 1,137 assessments were completed (95.5% response rate). All cases were considered suitable for orthognathic treatment, with 38% deemed suitable for SFA. Agreement on SFA suitability was fair to moderate, with good intra rater consistency. Overall and transverse tooth-fit, when models were hand articulated, were key drivers for SFA suitability. Consensus ranking identified transverse skeletal relationship, incisor inclination, and crowding as important features. Additional features, including centrelines and vertical relationships showed context dependent importance. Qualitative findings demonstrated greater nuance than rankings alone, highlighting how decisions were influenced by feature combinations and interdisciplinary interpretation.
Conclusions: SFA suitability is primarily determined by features affecting immediate post-operative occlusal predictability. Clinicians demonstrate fair-to-moderate agreement, with variability reflecting case complexity. These findings provide a UK-specific evidence base to inform case selection and support future clinical trials comparing SFA with conventional orthognathic treatment.