is Orthognathic (Jaw) Surgery?
Orthognathic Surgery & Orthodontics
Sequence of Treatment
Day of Surgery
|Orthognathic (Jaw) Surgery|
What is Orthognathic (Jaw) Surgery?
|The following information is designed to help you understand the combined treatment involving orthodontics and orthognathic surgery, as well as events associated with the surgery and hospitalization. Please discuss any concerns or questions with Dr. McDonald.|
Orthognathic Surgery & Orthodontics
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.
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.
Sequence of Treatment
Combined orthodontic and surgical treatment usually requires about 18-24 months to complete. The treatment may be divided into four stages:
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.
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.
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.
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.
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.
Day of Surgery
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.
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.
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.
Nausea and Vomiting
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.
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.
Cleaning the 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
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.
Day of Discharge
Movement and Speech
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.
Transitional Phase After Surgery
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.
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
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.
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
Ability To Complete
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
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.
Sports and Exercise
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.
top of page