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Orthognathic Surgery

“Orthognathic surgery is the main reason I became a Maxillofacial surgeon and even now after 30 years treating patients it is the procedure I love most.

It encompasses the artistic assessment of what is attractive with the technical aspects of how to achieve this.

Within surgery it has one of the highest satisfaction rates of all surgery from the Patient’s point of view. Whist improvements in function are important the greatest impact is the increase in self confidence that is reported in almost all patients”

Helen Witherow

What Is Orthognathic Surgery?

Orthognathic Surgery – “Surgery to create straight jaws” is the literal meaning of orthognathic surgery. It is usually undertaken to improve both the function and appearance of the upper and lower jaws, the teeth and the facial appearance as a whole. It is undertaken by a team consisting of a Consultant Orthodontist, along with a Consultant in Oral and Maxillofacial Surgery. Sometimes other professionals need to be involved such as Psychiatrists, Dieticians and Speech and Language therapists.

Orthognathic surgery is undertaken by Maxillofacial surgeons and requires brace treatment by an orthodontists. The aim of which is to improve function and aesthetics of the face by moving the jaws and teeth into an optimal position. The process starts with an assessment with a Consultant and then jointly within a Multidisciplinary team. The team includes an experienced Orthodontist and often a Psychologist.

Orthognathic treatment has been shown to improve oral function, improve both dental and facial appearance and improve health related quality of life. In some cases the results of jaw surgery can be enhanced with the addition of other procedures such as nose surgery (rhinoplasty), chin surgery (genioplasty), or the placement of facial implants.

Most Orthognathic surgery requires brace treatment before during and after surgery but sometimes it is possible to start with surgery and then have orthodontics after (surgery first techniques). Some patients ask if it possible just to have surgery alone but the way the teeth bite together (occlusion) is essential to maintain stability of the bite.

What Causes jaw problems?

Large, small or asymmetric jaws may develop without a specific cause but often there is a genetic predisposition to uneven jaw size. Other causes include disturbance or jaw growth during development such as after a fracture of the jaw bone in childhood. Some children with specific conditions such as cleft lip and palate, or a syndrome known as hemifacial microsomia are more likely to require this type of treatment.

Usually jaw discrepancies are noted as children grow and becomes more marked at puberty. Usually treatment is undertaken towards the end of growth during late teenage years, although in some cases maybe started earlier. Jaw surgery before the end of growth runs the risk of needing repeating as growth can change jaw shape so your surgeon or orthodontist will delay starting orthodontic treatment until they feel you will be finished growing at the time of surgery.

Is there an upper age limit for treatment?

Adults can also undergo this type of treatment. This maybe indicated for a number of reasons:

They may of been unaware the treatment was available when they were younger and have functional problems with eating or with there occlusion (bite) teeth, or even wish to improve there appearance.

They may ned this treatment due to facial surgery for trauma or other head and neck pathology causing disturbances in the bite (occlusion).

Sometimes we see patients who have had previous camouflage surgery eg a chin implant, or orthodontics to hide a small jaw and who would also benefit from orthognathic surgery.

What problems are caused by abnormal jaw relationships?

Mild jaw deformities and disturbances in the bite are relatively common and usually cause problems with the alignment of the teeth. This can sometimes be treated with the use of braces alone. In the UK this type or treatment is usually carried out by an orthodontist in high street practise. More severe facial deformities and jaw discrepancies cause a number of concerns and these patients are usually treated in a hospital setting with a Consultant Orthodontist and Consultant in Oral and Maxillofacial Surgery working together.

If dental and facial appearance is compromised this can lead to problems with increased stress and difficulty in forming interpersonal relationships, especially during the important formative teenage years. This ultimately reduces quality of life of the patient.

Jaw function can be compromised and this can result in problems with eating, damage to the gums and palate due to a traumatic bite, jaw muscle and jaw joint problems and speech difficulties.

What does Orthognathic Treatment involve?

Patients or there parents usually seek advice initially from their dentist or GP. Older patients may seek advice for camouflage treatment directly from cosmetic surgeons and these patients should really be assessed fully by a Consultant Maxillofacial Surgeon and Consultant Orthodontist prior to proceeding to camouflage surgery so that they can be fully informed of all treatment options and complications before proceeding to surgery.

 

It is recognised that the gold standard for orthognathic treatment is provided in the hospital setting using the team approach. The clinicians working in this setting have all undergone the appropriate training and have extensive experience in this type of treatment. This multidisciplinery team approach allows close communication between all involved in a patients care.

 

Once a problem has been identified a referral can be made and the patient assessed fully by both a Maxillofacial Surgeon and an Orthodontist. This initial assessment will involve a full history and examination. Usually radiographic examination of the face and jaws with either x-rays or CT scans, impressions of the teeth and clinical photographs are undertaken for records and for undertaking cephalometrics (skull radiographic measurements). Using this information computer software programming can simulate proposed tooth and jaw movements to give a guide as to the post treatment outcome.

 

Once a patient has nearly finished growing (usually at 15-18 years of age) treatment planning can be discussed with patients and parents. If the patient then wishes the initial phase of the treatment can start. Prior to any brace treatment all dental work should be completed and oral hygiene should be good. If this is not the case treatment will be delayed until good oral health has been achieved. This is because braces increase the risk of dental decay and can be detrimental if good oral hygiene measures are not undertaken.

Treatment Stages

  1. Pre-surgical orthodontic treatment with braces and any necessary dental extractions. This work is usually undertaken by a Hospital Consultant Orthodontist. Braces are attached to the teeth which are then adjusted on regular basis. This allows the teeth to straighten in each jaw so that the two jaws can fit together properly. At the start of this treatment it maybe necessary to have some teeth removed to make room for the teeth to be moved in the jaws. The commonest teeth to be extracted are the premolar teeth although this may vary. Sometimes heavily filled teeth maybe extracted rather than healthy teeth if it is thought there long term prognosis is not as good as the other teeth. Also at this time if you have wisdom teeth present in the lower jaw, they should also be removed. This is because lower jaw surgery is undertaken in the part of the jaw in which the wisdom teeth lie. If they are left in place the jaw surgery can be less predictable and so are usually removed at the start of treatment in order for bony healing at the extraction site to take place. This initial orthodontic stage usually lasts 12-18 months
  2. Once tooth alignment has been achieved a final surgical plan is made between the maxillofacial surgeon and the orthodontist. Impressions of the teeth are undertaken and using specially trained maxillofacial technicians the planned surgery in simulated on the models of the teeth. This allows acrylic splints to be made which allow the surgeon to correctly position the teeth at the time of surgery. Both immediately prior to, and following the surgery, the frequency of the visits to both surgeon and orthodontist will increase to ensure the preparation for surgery is correct and the immediate post operative position of the teeth and jaws is optimised and maintained
  3. Post-surgical orthodontics. Following surgery there may be some fine adjustments that need to be made to the position of the teeth, therefore the braces usually stay in position until 4-6 months after. Following removal of the braces you will need to wear retainers on your teeth for a year initially and then at night only for many years as teeth will always have a tendency to try and return to the position they came from!

Why is Orthognathic surgery so popular?

Whether we like it or not we are all hard wired, through evolution to react to a person’s appearance, particularly their face. We make instantaneous judgements within seconds of meeting a person based only on what they look like. Often those judgements are not correct and over time when we know someone better we change our opinions, however the “Halo” effect where we attribute positive attributes to attractive people is a well-recognised phenomenon.

There are certain facial proortions that are pleasing and others that convey a more negative message. Some facial features are considered male and some female. Men tends to have a slightly stronger jaw (mandible) whilst a female has smaller jaws. We also associate certain characteristics with these differences, a larger jaw in a man tends to be associated with strength, confidence and assertion. However, an abnormally large jaw may be associated with aggression. A small jaw in a man conversely may be allied to weakness and timidity. Similar a woman with a large jaw may be considered less feminine but also a disproportionately small jaw is associated with weakness.

Facial asymmetry also has an impact on people’s first impressions. Interestingly small degrees of asymmetry are considered attractive but larger ones are less well tolerated and can be improved with orthognathic and other facial procedures.

Is it worth it?

Initially you may think this is not for you, as both the treatment time and surgery require significant time off work, discomfort etc. However the end result is that your facial skeleton is healed in its new position and this will remain with you for the rest of your life. Patient satisfaction for this type of treatment is very high despite the long course of treatment involved. There are many patients who have undergone this type of treatment and would be more than happy to discuss their experiences.

Functional improvement with orthognathic surgery

Orthognathic surgery can improve a number of other aspects including the occlusion (the way the teeth meet together), Oral health (distributes wear more evenly on the teeth), the ability to eat more easily and the appearance of eating, speech, jaw pain (although it can also make it worse), sleep apnoea and improvements to nasal breathing.

What is involved in the surgery?

Single jaw surgery – this can be the top jaw, the Maxilla, or the lower jaw, the Mandible.

Bimaxillary surgery – this involves surgery to both the upper and lower jaw, (Maxilla and Mandible).

Genioplasty – this involves surgery to the chin

In all of the above cases the surgery is undertaken under a general anaesthetic, Bone is divided and fixed in the predetermined position with very small titanium plates. These plates usually stay in for ever but can be removed if requested after approximately 3 months. This does however require another general anaesthetic.

3D planning is sometimes used with difficult more complex cases, particularly with asymmetry. This can improve bony accuracy.

Bimaxillary surgery is more major surgery and involves staying in hospital for 1-2 nights. You will need up to 4 weeks off work or taking it very easy and for a period of time you will not be able to open your teeth for at least 1 week. Tight elastic bands are placed between the teeth to ensure the occlusion is maintained. During this period you will be on a liquid diet for 1 week ie soups and smoothies . For the next 5 weeks a soft diet is adequate ie scrambled egg, mashed potato, yoghurt, pasta.

Complications

With all surgery there can be complications and for this reason we need to ensure patients are as healthy as possible. Operating around the airway is someone morbidly obese can be dangerous because of the difficulty the anaesthetist can have in ventilating a patient whilst asleep. Smoking carries with it increased risks both during the procedure, after and healing.

Numbness – certain sensory nerves (feeling nerves) are almost always bruised during surgery , those to the lower lip and chin (inferior alveolar nerve), those to the top lip and cheek (infra-orbital nerve) and to the roof of the mouth (palate).

These nerves do not affect the movement of the muscles. Usually the numbness recovers but it can take 18 months to 2 years to recover and 20% of patients have some permanent numbness. However we have found that those patients that do have some permanent numbness still feel the benefits of the surgery have out weighed this complication.

Infection, bleeding, asymmetry and very rarely damage to other cranial nerves or blood vessels can occur.

Body dysmorphic disorder

BDD is a rare condition which affects some people attending for aesthetic surgery. It is very important for the patient and the clinician to recognise this before any treatment is started as surgery is not the best treatment for this condition.

BDD is a condition where a person becomes abnormally focused on an aspect of their body, often others can not see the problem or not to the same degree the patient. Surgery in these cases particularly without psychological support may make the condition worse.

All patients undergoing facial surgery are asked to see out Psychologist before to talk about their concerns. Our experience is that the vast majority of patients find this very helpful.

Which Surgeons perform this procedure?

Those of us at The Face Surgeons that undertake Orthognathic surgery are:

Helen Witherow

Katherine George

Caroline Mills

Further readingL https://www.bos.org.uk/Your-Jaw-Surgery