Craniofacial Anomalies

Orthognathic (Maxillofacial) Surgery

What is orthognathic (maxillofacial) surgery?

Orthognathic surgery combines orthodontic treatment with surgery of the jaw to correct or establish a stable, functional balance between the teeth, jaws, and facial structures. The goal of maxillofacial surgery is to treat any jaw imbalance and the resulting incorrect bite, which could adversely affect the cosmetic (esthetic) appearance as well as the proper functioning of the teeth. This procedure involves diagnosis, treatment planning, and execution of treatment by combining orthodontics and oral/maxillofacial surgery to correct musculoskeletal, dento-osseous, and soft tissue deformities of the jaws and associated structures.

What does "orthognathic" mean?

The word "orthognathic" was coined by an oral/maxillofacial surgeon and means "straight jaws," just as orthodontics means "straight teeth." Prior to that time, the term surgical orthodontics or "facial orthopedics" was used to describe this medical specialty.

When is orthognathic surgery required?

Orthognathic surgery is needed when jaws do not meet correctly and/or when the teeth do not seem to fit with the jaws. The teeth are straightened with orthodontics, and corrective jaw surgery repositions the mal-aligned jaws. This not only improves the facial appearance (esthetics), but also ensures that teeth meet correctly and function properly.

Who needs orthognathic surgery?

There are many different types of abnormalities of the jaw structures that can result in facial deformity and improper bite. These abnormalities in the jaws and facial bones may be congenital (present at birth) or developed during growth and development. They may also be acquired after birth as a result of hereditary, environmental influences, or trauma/illness to the face.

It has been estimated that dentofacial (involving the teeth and face) deformities affect approximately 20 percent of the population.

Any individual with difficulty in the following areas should be evaluated for possible orthognathic surgery:

• difficulty in chewing, biting, or swallowing
  
• speech problems
  
• chronic jaw or TMJ (temporomandibular joint) pain
  
• open bite
  
• protruding jaw
  
• breathing problems

What specialists are involved in the evaluation for orthognathic surgery?

Successful orthognathic surgery requires the cooperation of many specialists, which may include the following:

• oral/maxillofacial surgeon  - an orthopaedic facial surgeon responsible for treating a wide variety of dental problems, including the removal of impacted teeth and reconstructive facial surgery. This dental specialty also includes the diagnosis and treatment of diseases, injuries, and defects involving both functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.
  
  
• orthodontist - a specially-trained dentist who specializes in the development, prevention, and correction of irregularities of the teeth, bite, and jaws. Orthodontists also have specialized training in facial abnormalities and disorders of the jaw. A patient often consults an orthodontist after receiving a referral from his/her general dentist.
  
  
• periodontist
  Periodontists are responsible for the care and prevention of gum-related diseases, guided bone regeneration, and dental implants. It is the specialty of dentistry that includes the prevention, diagnosis, and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes, and the maintenance of the health, function, and esthetics of these structures and tissues.
  
  
• prosthodontist
  Prosthodontists are dental specialists who have undergone additional training and certification in the restoration and replacement of broken teeth with crowns, bridges, or removable prosthetics (dentures). It is the branch of dentistry that also specializes in understanding the dynamics of the smile, preserving a healthy mouth, and creating tooth replacements. Prosthodontists often work closely with other members of the oral health care team in restoring natural teeth, replacing missing teeth, and/or developing artificial substitutes for damaged oral and maxillofacial tissues. In addition, prosthodontists also have specialized training in the following:
• • post-oral cancer reconstruction
  • jaw joint problems (i.e., temporomandibular joint disorder)
    
    
• endodontist
  Also called pulp specialists, endodontists have undergone specialized training in performing root canal therapy. This particular branch of dentistry is concerned with the morphology, physiology, and pathology of the human dental pulp (the soft tissue between the tooth's outer enamel and the dentin) and periradicular tissues - including the prevention and treatment of diseases and injuries of the pulp and associated periradicular conditions.
  
  
• neurosurgeon  - a surgeon who specializes in the brain, spinal cord, and nerves; also coordinates all surgical interventions of head abnormalities with the craniofacial surgeons (i.e., craniosynostosis).
  
  
• ophthalmologist  - a physician who specializes in the structures, functionality, and diseases of the eye. An ophthalmologist evaluates and plans treatment of associated eye problems in coordination with other surgical interventions.
  
  
• otolaryngologist (ear-nose-throat specialist)  - a physician who will assist in the evaluation and management of ear infections and hearing loss that may be side effects of your child’s cleft abnormality.
  
  
• plastic/craniofacial surgeon  - a surgeon with specialized training in the diagnosis and treatment of skeletal abnormalities of the skull, facial bones, and soft tissue; will work closely with the orthodontists and other specialists to coordinate a surgical plan.
  
  
• speech and language specialist - a professional who will perform a comprehensive speech evaluation to assess your child's communicative abilities and who will closely monitor your child throughout all developmental stages.

These professionals will work as a team to provide the diagnosis, treatment plan, and actual execution of the treatment.

What are the basic goals of orthognathic surgery?

The specific goal for orthognathic surgery will vary from patient to patient, depending on the actual diagnosis. In general, the team will address the following:

• function (normal chewing, speech, ocular (eye) function, and respiratory function)
  
  
• esthetics (establish facial harmony and balance)
  
  
• stability (avoid short- and long-term relapse)
  
  
• minimize treatment time (provide efficient and effective treatment)

What is involved in the evaluation and diagnosis of orthognathic surgery?

The most important aspect of overall patient management is a thorough evaluation and diagnosis. Patient evaluation for orthognathic surgery can be divided into four main areas:

• patient concerns or chief complaints
  
• clinical examination
  
• radiographic and imaging analysis (x-rays)
  
• dental model analysis

After an examination by each of the orthognathic surgery team members (dentist, orthodontist, and maxillofacial/oral surgeon), a diagnosis is made and a coordinated treatment plan is prepared. The complete process usually takes place in several stages over the course of one to two years.

Treatment process of orthognathic surgery:

The treatment process occurs in stages. Any general dental maintenance, prevention, or restoration should be performed prior to orthodontic and surgical intervention. Then, the first stage of treatment is the alignment of the teeth into a stable relationship with the underlying jaw by orthodontics, which prepares the dental arches for the surgical repositioning. This stage usually takes the longest, from a few months to over a year. At this stage, the abnormal bite (malocclusion) may become more noticeable.

Once ready for the surgical procedures, the orthodontist and maxillofacial surgeon will review photographs, x-rays, and dental models to finalize the surgical plan. The operation may involve a single jaw or both jaws (maxilla and mandible). The surgery may also be combined with other procedures, such as rhinoplasty (nose correction) or genioplasty (chin correction) to improve the general appearance of the face.

How long is the surgery?

The procedure may take two to four hours, depending on the complexity. Most patients are kept in the hospital for two to five days, depending on the specifics of the procedure and the post-operative condition.

How long is the recovery?

Most patients return to their normal activities within a week or two after their surgery. The surgeon will monitor the healing, and review the changes in the facial structures and occlusion (bite). The orthodontist will adjust the braces to fit the new repositioned jaw. Orthodontic treatment may continue for several months to ensure optimal positioning of the teeth.