Orthognathic surgery is performed on the jaws to put them into the correct position. Orthognathic (pronounced or-tho-na-thik) means literally “straight jaws”. this will improve a person’s ability to chew and speak. Breathing may become easier for some people. The surgery may also improve facial appearance.
Jaw problems that may be corrected by orthognathic surgery include jaws that are too large, too small, too far forward, too far back, or crooked. There may be a significant gap between the upper and lower front teeth.
The causes can vary. For example, the problem may have :
- Been present at birth
- Developed as the jaws grew
- Occurred due to trauma or disease.
When a person needs orthognathic surgery, it is usually performed in conjunction with orthodontic treatment to correct problems with the occlusion, commonly called “bite” (that is, the contact of the teeth between the upper and lower jaws as they meet during chewing when the jaws are closed).
Symptoms and signs :
Symptoms and signs that may indicate a need for orthognathic surgery include problems with the following :
- Chewing or biting food
- Speaking clearly
- Jaw pain
- Unbalanced facial appearance
- Facial injury or birth defects
- Uneven or rapid wearing down of teeth
- Open bite (space between upper and lower front teeth or back teeth when mouth is closed)
- Receding chin
- Protruding jaw
- Inability to make lips meet without effort
- Chronic mouth breathing with dry mouth and inflamed gums
- Sleep apnea (when sleeping, breathing problems such as snoring)
Your surgeon will inspect your face and jaws, and may make facial measurements, take photographs or use video imaging, or recommend X-ray examinations of your jaws and jaw joints.
Your surgeon may assess tooth wear and tooth mobility to determine whether your teeth fit together correctly. Your surgeon may make plaster models of your teeth and jaws to assist treatment planning.
Realistic expectations : when you are making the decision whether to have surgery, you must keep in mind that your surgeon cannot guarantee that the surgery will always be successful or that the surgery bears no risk.
The operation and it’s outcome might not meet your expectations.
You are encouraged to discuss fully with your surgeon the treatment to be done and the likely outcome you should expect.
Your surgeon may recommend surgery if your jaw problem cannot be treated effectively by orthodontics alone. The recommended treatment will depend largely on the diagnosis.
Surgery is often combined with orthodontic treatment and may take from several months to two years or more to complete. You must be prepared for the overall treatment to take a long time. In some patients, psychological counseling may be an important part of the treatment.
Decide whether to have surgery after discussing the details with your surgeon. Your surgeon will be pleased to discuss the benefits, risks and limitations of treatment, and of not having treatment. Not treating a functional problem may :
- Prevent you from being able to bite and chew food properly, close your lips and speak clearly.
- Compromise your dental health in the long term.
The decision to have surgery is yours. Make the decision when you are satisfied with the information you have received and believe you have been well informed.
Your surgeon will record your symptoms, previous treatment (if any), medical and dental history, and social and lifestyle factors. Your surgeon needs to know your complete medical and dental history to help plan the best possible treatment. You may be asked to complete a questionnaire.
Give your surgeon a list of ALL medicines you are taking now or have been taking recently. This includes aspirin, cough medicines, hormone replacement medicines, and the contraceptive pill. Tell your surgeon if you have ever had an allergy or bad reaction to anitibiotics, any medicine or general anaesthetic.
Tell your surgeon if you bleed heavily when you are injured or have surgery, or if you have any blood disorders, such as haemophilia. Surgery is usually not done during pregnancy. Advise your surgeon if you are, could be, or plan to become pregnant.
Your surgeon can advise you about coverage by public health insurance, private health insurance and out-of-pocket costs. you may want to ask for an estimate which lists the likely costs. This includes the anaesthetist, medical and hospital fees, and other items. As the actual treatment may differ from the proposed treatment, the final account may vary from the estimate. It is better to discuss costs before and during treatment rather than afterwards.
You may need to have teeth removed before orthodontic treatment to make space for movement of remaining teeth.
The orthodontist will straighten the teeth before surgery to make the surgery simpler and to ensure a stable result. Orthodontic treatment usually lasts about 12 to 24 months, and surgery will be undertaken at some interim point. During this time you will be wearing braces and may need to have them adjusted regularly.
You may think that your bite is getting worse during orthodontic treatment. However when the surgeon moves your jaws into proper alignment during orthognathic surgery, the teeth will be in their proper position. Orthodontics in conjunction with orthognathic surgery can optimize your outcome.
Before your orthodontic treatment is complete, the surgeon makes final preparation for the surgical procedure. Further records are taken.
The surgeon and orthodontist will arrange surgery when they determine that your teeth are in the correct position.
Your surgeon may use X-ray examinations and models of your teeth and jaws to decide on the surgical procedure (to be performed on your jaws) and to anticipate the results.
A plastic dental splint can be made from the models of your teeth and jaws to act as a guide for proper tooth and jaw alignment during the surgery.
Other surgical procedures : your surgeon may suggest other procedures to maximize the outcome of the surgery, such as grafting or cosmetic procedures.
Orthognathic surgery is performed in hospital under general anaesthesia, which puts you in a sleep-like state so there is no pain during surgery.
In some cases, you will be admitted to hospital on the day of your surgery.
Do not eat or drink anything for six hours before surgery. If your surgery will be performed in the morning, do not eat or drink after midnight the night before. Your surgeon will give you more instructions.
Rarely, some select patients may need to donate their own blood before surgery. This is usually done two to four weeks before surgery. If there is significant blood loss during surgery, these patients can be transfused with their own blood. In some areas. A fee may be charged.
The surgeon carefully cuts the bone and moves the jaw as required, for example, a small jaw may be lengthened, or a large jaw may be reduced in size. Incisions are usually made inside the mouth, so no scars appear on the face. If the surgeon has to make an external incision, care is taken to make it natural skin creases.
Once the jaws are placed in the desired position, they are fixed permanently with small bone plates and screws.
Depending on the complexity of the case, the surgery may take from one hour (for a single jaw procedure) to four hours (or more in some cases) for combined upper and lower jaw surgery.
Your stay in hospital will typically vary from one to three nights depending on the complexity of the surgery and your rate of recovery. You will receive intravenous fluids and medications to prevent dehydration and infection, and to minimize swelling and pain.
The intravenous line and drip will remain attached to your arm after surgery until you are able to drink properly and take all your medications by mouth. The quicker you begin eating, drinking and moving about, the quicker you will be discharged from hospital.
- Stitches :
Dissolving stitches are used in most cases. These dissolve gradually over three to four weeks. If they fall out earlier, do not worry, as long as there is no persistent bleeding
- Jaw support :
In some patients the jaws may be held together with orthodontic devices during healing.
- Oral hygiene and brushing :
Meticulous cleanliness and care of the mouth is essential for rapid healing and prevention of infection. Brushing is difficult during the first week after surgery. At least four times daily, rinse your mouth with warm salt water and chlorhexidine mouthwash as prescribed, especially after meals.
- Diet :
Eat only soft foods for four to six weeks until swelling and discomfort subside. Adequate nutrition is essential for healing. In the early stages, eat small portions five to six times a day, which will be difficult due to discomfort. Your surgeon can arrange dietary advice for you. In the later stages of healing, you can gradually return to a normal schedule of meals. Rinse your mouth immediately after each meal.
- Work or school :
Take at least two weeks off work or school. A medical certificate can be supplied to cover you for 14 days or longer as required.
- Appearance :
Your appearance may have changed somewhat, so you should be prepared for signs of surprise from your family and friends. It will not take long for them to adjust.
- Orthodontist :
Your surgeon will inform you when you are ready to return to your orthodontist to adjust your bands. This is often two to three weeks after surgery. The braces will remain on your teeth for a further six to 12 months, so your bite may be adjusted by the orthodontist to give the best result.
- Follow-up care :
After your orthognathic surgery, you may require a further six to 12 months of orthodontic treatment to help “fine tune” the position of the teeth and the bite. Your surgeon and orthodontist will want to see you periodically to be sure your teeth and jaws are staying properly aligned. Maintain good oral hygiene, and visit your family dentist regularly.
All surgical procedures have some risk. Despite the highest standards of surgical practice, complications are possible. While the surgeon makes every attempt to minimize risks, complications can occur that may have permanent effects.
It is not usual for a doctor to dwell at length on every possible side effect or rare, serious complications. However, it is important that you have enough information to weigh up the benefits and risks of surgery. Most people having orthognathic surgery will not have complications, but if you have concerns about possible complications, discuss them with your surgeon.
The following possible complications are intended to inform you, not to alarm you. There may be others that are not listed.
- After general anaesthesia, difficult swallowing, a sore throat, and generalized muscle pain may occur. These usually disappear by the following day. Vomiting may occur after a general anaesthetic and for one to two days afterwards. Medication can treat this. Although rare, the risks of general anaesthesia can include bronchitis, pneumonia, hoarseness or voice changes, heart attack, stroke and death. Elderly patients and heart patients may be at greater risk of heart attack.
- All surgery has a risk of infection, especially in diabetic patients. Risk is low after orthognathic surgery, but infection may develop around plates and screws. Antibiotics are often prescribed before surgery to prevent infection. If infection occurs, symptoms start at about 10 to 14 days, with pain, swelling and a bad-tasting discharge in the mouth. If infection or bleeding occurs, call your surgeon at once. Rarely, the oral incision may need to be re-opened, cleaned and re-stitched.
- Prominent scarring of intraoral incisions is unusual. In most patients, such incisions heal well and quickly.
- Veins that are used for intravenous fluids and medications may become inflamed, with swelling, discolouration and restriction of arm or hand movement for some time.
- Pain and discomfort depend on the complexity of the surgery. Discomfort is worst during the first few days after surgery and then should gradually subside. Strong painkillers are provided. As discomfort decreases, you will change to tablets. The need for painkillers usually stops about seven to 10 days after surgery.
- If too much blood is lost during surgery, a transfusion may be needed. Bleeding may occur in the first 24 to 48 hours after surgery, particularly if you continue to spit, smoke, touch the wounds, or eat hot food. To minimize the risk of bleeding, sleep with your head elevated on pillows, do not smoke, do not rinse the mouth vigorously until the day after surgery, and get plenty of rest. If bleeding persists, the surgeon will be called immediately by nursing staff. If the wound becomes infected, bleeding may occur.
- Swelling is normal. Maximum swelling occurs 48 hours after surgery and subsides over three to four weeks. Most swelling subsides after 14 days. The more complex the case and difficult the surgery, the greater the swelling. For a few days, swelling may cause some difficulty in closing the molars together.
- Bruising of the face, neck and chest may occur as the swelling subsides. It usually resolves in seven to 10 days
- Sensation is impaired because nerves are moved and may be injured during surgery. The chin, lower lip, upper lip, cheeks and palate are the most commonly affected. Patients older than 40 who have certain types of surgery of the lower jaw are at greater risk of permanent numbness and loss of sensation. In most patients, sensation returns to normal within three to six months. Tingling and itching is a good sign that feeling is returning. Avoid biting your lips or placing hot food or drink next to the numb areas until return of sensation is complete. After upper jaw surgery, the sense of smell may be lost for a while.
- After upper jaw surgery, the nasal sinus will be affected for several weeks. In rare cases, the patient may need further surgery.
- Limited mouth opening, caused by swelling and later by general jaw stiffness, is normal after major jaw surgery. Elastic bands are placed between the teeth to support the lower jaw and guide the teeth into a proper occlusion after the surgery. Jaw function will gradually improve. Mouth opening returns to normal in four to six weeks. While the jaws are fixed into a rigid position, the muscles used in facial expression may not function properly because of general facial swelling.
- Bone screws do not usually come loose. If they do, the screws are removed after the bone has healed. Patients may need further surgery to remove wires, pins, screws, plates or splints.
- Wound separation is rare. Poor oral hygiene may cause a wound to open.
- In some patients, the bone can heal very slowly or not at all. Delayed union or non-union of the jawbone after surgery is rare in healthy patients. Smoking increases this risk. The jawbone may fail to heal where there is little or no bone contact between the areas where the bone has been cut. Further surgery may be needed if the bone heals too slowly. Such problems are usually overcome with bone grafting.
- Relapse of the new jaw position or unpredicted shifting of jaw structures is uncommon. If the jaw does not stay in its new position, the patient will usually need further surgery. The risk of relapse is greatest when the lower jaw is moved forward more than 10 millimetres in people who have stopped growing, and when the lower jaw is moved back in growing children or teenagers who had a protruding jaw. Relapse may occur with large movements of the upper jaw. This may require bone grafts to provide a more stable result.
- Uncommonly, teeth may die and have to be removed where bone is cut between or near the roots of teeth.
- The temporomandibular joint (TMJ) is the jaw joint that you can feel close to the ears when you move your jaws. TMJ pain or abnormal function can occur following orthognathic surgery. Surgery may aggravate existing TMJ problems and make further treatment necessary.
- Velopharyngeal incompetence occurs when the soft palate (velum) and throat (pharynx) do not seal the space connecting the mouth and nose during speech. This may occur after some types of upper jaw surgery in cleft palate patients. Speech may sound more nasal than it was before surgery.
Report to your surgeon :
Tell your surgeon at once if you develop any of the following :
- Temperature higher than 38 C or chills
- Severe pain, redness, bleeding or swelling of the operated site
- Nausea or vomiting
- Persistent bleeding
- Any concerns you have regarding your surgery.