Orthodontic treatment or wearing of braces can usually correct malocclusions (the poor fitting together of the upper and lower teeth). However, when the two jaws are different in size, shape, or position, orthodontics alone cannot align the teeth for a better fit. Surgery then becomes necessary.

Surgery corrects the fit between the jaws, whereas orthodontics corrects the fit between the teeth. Surgery involves the repositioning either the upper or lower jaw, or both, to get a better fit between the jaws. Combined orthodontics and surgical treatment therefore results in the likelihood of a better bite. The combined treatment is often necessary, because poor-fitting teeth generally occur in poor-fitting jaws.

From detailed studies of your case, your orthodontist and your oral and maxillofacial surgeon can recommend a program of combined treatment.

Orthognathic surgery is a well-established field; many of the surgical procedures were developed as early as the 1920s. Major advances were made in the 1960s, and these techniques have been continually refined over the years.

Preparing a case for orthognathic (jaw) surgery:

1. Types of Brackets

Bonded brackets are all right for the anterior and premolars but bands should be used on the molars. Headgear tubing should be on both upper first molars. This will ensure proper fixation at the time of setting the bones into their new location.

Metal, plastic or ceramic brackets are acceptable.

2. Hooks

Brackets with hooks should be used on all cuspid teeth. This will enable the use of elastics in the early post operative phase. The molar bands will also have hooks on them.

3. Need for Maxillary Expansion

If expansion of the maxilla is necessary, please make sure there is about 4 to 5 millimeters space between the root tips of the maxillary incisors. A diastema between the teeth is not necessary. This will allow for the cut in the bone so as not to damage the adjacent teeth.

4. Arch Wires

These should be passive so as not to cause movement in the teeth after the impressions for the splint are done. These are usually done 2 weeks before the surgery date. If they are not passive then the surgical splint may not fit and the bite will not be ideal.

No spring appliances or springs on the arch wire should be used close to the surgery.

Make the last adjustment no later than 6 weeks before surgery.

5. Pre-surgical Models

A set of pre surgical models should be done on all cases 6 to 8 weeks before the surgery date. This will allow you to assess the positions of the teeth and make any changes. This is an important step and will help avoid problems that can happen closer to the time of surgery. This will also help assess any width discrepancies between the jaws.

6. Spaces in the Arches

All spaces between the teeth should be closed prior to the surgery unless they are being left open for prosthetic replacement. The maxillary and mandibular incisors should be in their proper proclination.

7. Need for Extractions

These will be decided at the start of treatment. In mandibular advancement cases where the lower lip is well ahead or forward of the chin prominence, consideration should be given to removing the lower first premolars. This will give a better esthetic profile post-surgery and may negate the need for a genioplasty.

8. Curve of Spee

Whether to keep the curve or level it will be decided early in the treatment. If there is a prominent chin we would keep the curve so as to soften the chin with the mandibular advancement.

9. Consultation with the Oral Surgeon

This should be done at the beginning of the treatment. This will allow the surgeon and patient to meet and discuss both the surgery and fees. This will also help with the booking of the surgery in the hospital.

10. Post-surgical Orthodontic Care

This can resume 5 weeks after the surgery. The patient will be in light elastics while under the surgeons care. In larger advancement cases, class 2 elastics will be used for an extended period so as to minimize any relapse.

11. Midlines of the Teeth

These should be checked 4 to 6 weeks prior to the surgery If a single jaw surgery is to be done and the opposite jaw tooth midline is off facial midline, then advise the surgeon of your wishes. Should the operated jaw be placed on the opposite jaw midline or should it remain on facial midline. With 2-jaw surgery this will not be a problem

12. Maxillary Corticotomy Patients

Preparation requires the maxillary expander to be cemented in place. The patient needs to bring the adjusting key to the operating room. There also needs to be 4 to 5 millimeters space between the root tips of the maxillary central incisors. Cuts are made surgically along the lateral wall of the right and left maxilla as well as down the midline. The expander will be opened fully at surgery to make sure there is expansion and it is equal on both sides.

Combined orthodontic and surgical treatment usually requires about 18-24 months to complete. The treatment may be divided into four stages:

1. Treatment Planning
2. Orthodontics before surgery
3. Surgical treatment
4. Orthodontics after surgery

1. Treatment Planning

Your oral and maxillofacial surgeon and your orthodontist will be the main specialists working together to plan your program of treatment with you. They will use your dental and facial x-ray films, dental casts, photographs along with the clinical examination to plan your case.

2. Orthodontics before Surgery

Your teeth must be aligned before surgery. You may be required to wear braces for about 8 to 16 months. The braces are necessary to align the teeth sufficiently, in preparation for jaw alignment.

On your last visit to your orthodontist before your surgery, your braces will be modified so that they can be used in wiring the jaws together, at the time of surgery.

3. Surgical Treatment

Once your teeth are aligned, you will have another consultation with your oral and maxillofacial surgeon. Your progress will be reviewed as well as the recommended program. A plan for surgical treatment will be drawn up.

Details of the surgery, your hospital stay, and the recovery period are discussed at this time. The purpose of this consultation is to help you better understand the procedures involved in the surgery. You should feel free to ask questions at this meeting.

Hospital
Orthognathic (Jaw) surgery is performed in an operating room and requires that you stay in hospital for a few days in most cases. You will be given a general anesthetic that will put you to sleep for the duration of the operation.

Patients will usually stay in the hospital for 1 or possibly 2 days. On the day of your pre surgical office visit, we will record your medical history, give you a physical examination, and order laboratory tests if indicated.

A physical examination will be performed to make sure you are fit for the surgery and anesthesia. An anesthesiologist (doctor administering the general anesthetic) will examine you before the surgery and talk to you about general anesthesia.

Surgery takes place the next day. Patients are usually discharged on the first or second day after surgery. During surgery your jaws will be aligned and wired together. The braces on your upper and lower teeth will also be used in wiring your jaws together.

The wiring of jaws is known as "maxillomandibular fixation", and it allows satisfactory healing to occur. The fit between your upper and lower teeth is determined by a splint (small plastic template) positioned between your upper and lower teeth. This splint is specially made for you before the surgery, on the plaster casts of your teeth.

After Surgery
After surgery, your jaws will only be wired together while you are asleep. Afterward you will be in light elastics for about 2 weeks. In larger movements the elastics may be used for a longer period.

The diet will initially be liquid, but you will also be able to chew soft foods. These consist of pasta, mashed potatoes, rice, fish, etc.

The use of the bone plates and screws allows the jaws to be unwired. The bone plates are made of surgical titanium and are usually not removed.

You will not be able to feel these and will only see them on a radiograph. They may require removal if an infection develops in the surgery area.

Your jaws will be stiff when the wires are first removed. Elastics will be used to hold your bite together for the first 2 to 3 weeks. These may be removed to brush your teeth and when eating.

Usually by 4 to 5 weeks after your surgery your mouth opening will be full again, if not some physiotherapy may be necessary.

During the first 6 weeks after your surgery you will have regular visits with our office. This is to monitor your healing, jaw position and bite. Radiographs will be used to monitor your healing at various times.

The total period for complete bone healing is 3 to 4 months.

4. Orthodontics after Surgery

After healing takes place and your new jaw position is stable, your upper and lower teeth are further aligned for the best fit, now possible with your new jaw position.

Orthodontic treatment after surgery is about 6 to 12 months.

Medications to prepare you for anesthesia and to help you relax will be administered on the day of your surgery. When you arrive in the operating room area, an intravenous catheter (IV) will be inserted into your arm. This will provide needed fluids and medications, eliminating the need for repeated injections.

You will receive a general anesthetic in the operating room. While you are asleep, a breathing tube (endotracheal tube) will be passed through your nose into your windpipe. The tube is necessary because the surgery takes place in the mouth.

Medicated cotton tipped applicators will be placed in your nose to shrink the nasal tissues and ease the tube passage. You will be asleep during the actual surgery, and have no knowledge of the surgery itself.

After surgery, the breathing tube will be removed as soon as the doctors feel it is safe to do so. You will still be somewhat asleep when this happens and thus, will have no recollection of it being removed. The intravenous catheter will usually remain in place until you are discharged from the hospital.

Minor Bleeding
Following Surgery A little bleeding is common after surgery. Patients with upper jaw surgery may experience minor nose bleeds for about 10 days.

Fluid Intake
Drink clear fluids as soon as you can. You have to drink fluids so that the intravenous catheter can be removed. An average adult requires about 2 to 3 liters of fluid per day. This may sound like a lot, but you can drink that amount with constant sipping. You will not be able to use a straw.

Speech
After surgery, your ability to speak is affected by the design of your splint. This will be designed so as to affect your speech as little as possible and your speech will also improve with practice. Speak slowly and concentrate on each word you say. Generally, patients can be understood within 24 hours after surgery.

Pain
Patients report differing amounts of pain, depending on their perception of pain. Most patients describe a "discomfort" that is less than the pain experienced after the extraction of wisdom teeth. This will usually last for about 5 days and is well-managed with the pain medication. Patients with bone grafts may feel more pain than those without grafts.

Nasal Stuffiness
Patients with upper jaw surgery will experience some nasal stuffiness from the surgical procedure.

The stuffiness can be relieved by cleaning the nostrils and by using nasal sprays. Clean your nostrils with cotton-tipped applicators soaked in a solution of hydrogen peroxide and water (one part hydrogen peroxide to three parts water).

When using the nasal spray, spray until you taste the medication. Your nose should clear in about 5 to I 0 minutes. The stuffiness will usually be gone within 2 weeks after surgery.

If you have had upper jaw surgery, avoid blowing your nose during the first week after surgery.

Bone Graft
Patients undergoing upper jaw surgery may need to have a bone graft. The bone is usually taken from the hip to graft the upper jaw into its new position. This procedure takes place at the same time as the jaw surgery. Hip discomfort will decrease in 7 to 10 days.

After surgery, you will be transferred to the recovery room where your progress will be monitored closely. Visitors are not permitted here. In about 3 hours you will be transferred to your room, where family members will be free to visit you.

Visitors
Please limit visits to members of your immediate family. This may be an emotionally difficult time for your family, even though it may not be so for you.

Nausea and Vomiting
You may be nauseated. This is not a life-threatening situation, because your stomach is empty. If vomiting occurs, remain calm and turn your head to the side or lean forward so that any fluid produced is cleared from your mouth. Wire cutters are available for use in an extreme emergency, but it is very unusual to have to use them. They are taped to the head of the bed. Your nurses will help you through this adjustment period.

Swelling
After surgery, your face will be swollen. This swelling reaches its maximum within 36 to 48 hours and does not begin to decrease until one week after surgery. The swelling with lower jaw surgery will usually be gone in three weeks. The swelling with upper jaw surgery will appear to be gone in three weeks; however, a slight puffiness may persist for 6 to 12 months.

During your hospitalization, every attempt will be made to minimize the swelling. A special medication will be given intravenously to control swelling prior to surgery.

Ice packs will be applied as soon as surgery is over, and a medicated cream can be used to reduce the swelling of the lips.

Keep your head up as much as possible during the first week after surgery. Swelling is related to posture. By keeping your head upright and by walking as much as possible, the swelling around your eyes can be reduced.

Lip Numbness
With lower jaw surgery, The lower lip, teeth, and gums may have no feeling or feel numb (tingling,pain). This may be temporary and last up to a year or more, but may also be permanent.

With upper jaw surgery the upper lip, teeth, gums and side of the nose may have no feeling or feel numb (tingling, pain). This may again be temporary and last up to a year or more, but usually will not be permanent.

Medications
During your hospitalization you will be given antibiotics, pain medication, medicated lip cream, and nasal spray will be available. These will be continued when you leave the hospital, if necessary.

Walking
All patients, including those with bone grafts from the hip, should try to walk as soon as they can. Patients with hip grafts may need assistance initially.

Cleaning the Teeth
Brush your teeth with a soft toothbrush after every meal. Try to keep the brush in direct contact with your teeth. In addition to brushing, use a mouth rinse diluted with hydrogen peroxide (one part of each). Do not use a water irrigating device such as a "Water Pik" until at least 2 weeks after surgery. This force can break down the wounds if it is used immediately after surgery. However, 2 weeks after surgery a combination of the "Water Pik" and a toothbrush is useful for oral hygiene.

Splints
A splint (plastic template) is constructed from models of your teeth that have been placed into the new jaw position. The splint fits between the two biting surfaces of your upper and lower teeth.

During surgery, the jaws are divided and the splint is fitted between the upper and lower teeth to establish and maintain the new jaw position. The jaws are then wired together in this new position for 2 to 3 days. Following this, elastics are used for 2 to 3 weeks.

The splint is constructed from acrylic (clear plastic) and is not easily noticed. The splint design is determined by the type of surgery you will have. After the wires are removed you may continue to use the splint, depending on each particular case.

Weight Loss and Diet
You may lose 5 to 10 pounds after surgery, resulting from loss of appetite. Your appetite will return after about a week, bringing you back to your normal weight.

You should not attempt to diet. It is important to follow the dietitian's recommendations for good nutrition during the healing period.

When your jaws are wired, you will have to be on a liquid, high calorie, high protein diet. If your jaws are not wired or are released from fixation early, you will have to maintain a soft or blenderized diet until about 3 to 4 weeks after surgery. This will ensure that proper bone healing will take place.

Psychological Considerations
It is not unusual to feel gloomy or depressed after surgery. You may feel that family members and friends are not encouraging enough. This feeling usually passes as patients recover from surgery and their condition improves.

Day of Discharge
Patients are usually discharged 1 to 2 days after the surgery. You will be given the necessary medications to take home with you. A follow-up appointment will be arranged at our office. You may resume your normal activities apart from contact sports as soon as you are able. Your jaw is in a state of healing and should not be subjected to any repeated trauma. Full bone healing takes about 4 months. You should AVOID all contact sports for this period, until your jaw has fully healed.

Restricted Jaw Movement and Speech
Speech is difficult with wired jaws, but you will be able to speak. Face to face conversation will be easier to understand than telephone conversations. Speech will become easier with time.

Your jaws will be unwired 2 to 3 days after surgery. They will feel stiff because the muscles have not been used during this time. Even if the jaws are not wired they will still feel stiff due to the nature of the surgery.

Jaw movements will be difficult at first; however, exercises will help you to regain movement and flexibility. Eventually a normal diet can be resumed.

After the jaws are unwired you will require periodic checks to monitor your new jaw position for 5 to 6 weeks. Final orthodontic treatment cannot begin until your jaw position is stable and the full range of jaw motion is regained.

During this transition, elastic bands may be used to help hold your jaws together for several weeks. These can be easily removed to allow eating and cleaning of the teeth. This phase will end when the final orthodontic treatment begins.

Scars
Unless otherwise stated at your consultation appointment, orthognathic surgery is usually performed inside the mouth and leaves no external scars.

If a skin incision is necessary, then it will be placed in the best possible place to avoid an unsightly scar. Occasionally a skin scar may have to be revised after 6 to 8 months if poor healing occurs.

Skin incisions, in the neck area, to perform certain types of jaw surgery, can also affect local nerves in the incision area. This nerve helps raise the angle of the mouth when we smile. Damage of this nerve may result in weakness, or loss of movement of the lower lip area. This may be either temporary, lasting up to 1 year, or permanent. A nerve stimulator is used during the surgery to identify the location of this nerve, and thus avoid damaging it.

Stability of Your New Jaw Position
When your jaw is put into its new position the surrounding muscles are tending to pull it back to its old position. Resisting this pull are the elastics and bone plates and screws. The stability or ability of the jaw to stay in its new position, is excellent with the plates and screws.

Occasionally there may be some changes in the position after the surgery. The braces can usually correct most of these minor changes.

Still very occasionally, a repeat surgery may be necessary, if the jaw position changes significantly. This change is unpredictable and is most likely due to changes in the jaw joint area.

Larger movements will have a greater chance of change after the jaw surgery. Further treatment may be necessary if any changes occur.

Bone Grafts
Occasionally bone may be necessary to allow the jaws to heal in their new position. This is usually taken from the hip area. The need for this will be discussed with you at your consult visits.

This will involve a small skin scar with the bone taken from the inner part of your hip bone. The hip will usually be sore for the first 2 to 3 weeks. Usually you will be able to get up and walk the day after your surgery.

There are no long term affects to the hip area after taking the bone graft. Occasionally you can get some numbness in the skin over the upper part of your leg, after the bone graft. This is very uncommon and does not lead to any walking problems. It can be either temporary or permanent.

Need For Blood Transfusions
After Your Surgery A blood transfusion is not necessary with jaw surgery. To minimize the blood loss during surgery, your blood pressure will be slightly lowered during the surgery. This will minimize any blood loss, and thus making a blood transfusion unnecessary.

Ability To Complete The Surgery
Very, very rarely it may not be possible to complete the surgery. This is due to the bone separating in a wrong direction. Due to this fact, the bone may not be able to be placed in its new position, to correct the bite. This is more common in the lower jaw.

If this happens during the surgery, the surgeon may have to place the jaws in the original position and not in their corrected or planned position. The jaws would need to heal for 6 to 8 months before the surgery could be performed again. A modified procedure may be necessary at the later date, to try and avoid the same problem.

Abrasions On The Skin
Rarely one may get a small abrasion on the skin, around the mouth area. This is due to the fact, that it can be difficult to perform the surgery, through the mouth opening. If this happens you will see a red area usually less than 5 millimeters.

This may remain red for up to 8 to 10 months. It will usually heal without a scar. Full healing may take up to 12 months. If it does not completely disappear then it may require a surgery to remove the area. This will leave a thin line white scar that usually will not be noticeable. It should be emphasized that this occurs very rarely, as extreme care is taken, in all the surgical procedures.

Injuries
Injuries to adjacent teeth, roots, fillings or bridgework can occur during jaw surgery. These may require appropriate dental care at a later date. Very occasionally a tooth may turn black after jaw surgery. This happens as the blood supply to the tooth has been reduced. This can not be predicted or avoided in most cases. It would require a root canal treatment and bleaching of the tooth.

Prolonged Recovery
This happens very rarely and can be due to a variety of causes. Maintaining a normal amount of food and liquid intake daily will help speed up your recovery.

Sports and Exercise
You will need to be careful with your jaw(s) after orthognathic surgery. Your bone will take about 4 to 6 months to fully heal. During this time your jaw(s) should not receive any direct impacts.

It will take at least 4 months healing to allow any aggressive or contact sports. This will also include any sports that use balls that can damage your healing jaw(s). You are encouraged to start light sports or exercise as soon as you are able. If you have any questions regarding this please discuss this with Dr. McDonald.

Your medical insurance will cover the surgery, hospitalization, and general anesthesia as outlined in your plan.

There is an additional pre-operative work-up fee that may or may not be covered by your dental insurance. This will vary from case to case and includes all the preoperative x-rays, photographs, dental casts, model surgery to make the splints, and planning that goes into your case.

The consultation fee is not included in the preoperative work-up fee. This will be discussed in detail with you and if there are any questions please feel free to ask them.

All fees are required to be paid prior to surgery.

Jaw surgery is a common surgery in today's world to correct bad bites. As you can see from the above discussion that there are many phases of treatment and possible risks involved. You should make sure that you fully understand the treatment, recovery, and all of the potential risks involved before proceeding with the surgery.

Should you wish to talk to patients that have undergone this type of surgery, then please let your orthodontist or our office know, so that we can provide you with a list of names.

The more that you understand about the surgery, recovery and possible complications involved, the easier the recovery will be, from the surgery.

If you have any questions regarding your consultation or surgery, please feel free to contact the office.

Should you like to proceed with the surgery, please notify our office, so that you can be placed on the surgery waiting list, at the start of your braces.

If you would like to speak with any of our former patients, please ask the receptionist, and we will provide a list of names and phone numbers.