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Many patients have facial cosmetic problems caused by abnormal growth of their facial bones. These problems are usually corrected with surgery to reposition the jaws rather than cosmetic soft tissue surgery. The word “orthognathic” comes from the Greek words “orthos”, meaning straight, and “gnathos”, meaning jaws. Orthognathic surgery "straightens" the jaws and corrects cosmetic and functional problems.
Individuals with imbalance of the jaws usually have dental problems related to a "bad bite". A "bite" is the way the teeth fit together, which is know as the "occlusion". A bad bite is called a "malocclusion". Some people note that their teeth are crooked or crowded and do not fit together well. If the teeth do not fit together properly, the chewing muscles may be strained, which can produce headaches and TMJ (temporomandibular joint) disorders. Patients may have been told that they need orthodontic treatment (braces) to improve their bite. In these individuals the bad bite has usually been caused by the imbalance in facial bone growth.
The upper jaw (maxilla) may be too wide or too narrow, too long or too short, or too far forward or too far back, to fit the lower jaw (mandible) properly. If the upper jaw is vertically too long, the individual usually has a gummy smile, or a gap between the upper and lower front teeth (open bite) when they bite their back teeth together. This group of problems is called Long Face, or Long Face Syndrome. If the upper jaw is too short, the whole face looks too short and the upper teeth may not show enough, even when smiling. The lips are usually pushed together too much when the person bites their teeth together, and a deep horizontal groove forms between the lower lip and chin. This combination of problems is called Short Face, or Short Face Syndrome.
If the lower jaw is too small, or the upper jaw is too big, an under-bite develops and the chin looks receded. This is called a Class II malocclusion. If the lower jaw is too big, or the upper jaw is too small, the chin appears too far forward, and the lower teeth are out in front of the upper teeth. This is called a Class III malocclusion.
One side of the face may be over or under developed, producing an asymmetry in which the face appears tilted or "off center". This may be due to abnormal growth in one or both jaws. The degree of the asymmetry will determine whether one, or both jaws, will need to be repositioned. Usually, the asymmetry is mild enough that only the jaw being moved to correct the malocclusion needs to be moved slightly sideways to correct the asymmetry.
Either jaw can be surgically repositioned to correct the malocclusion (bad bite), and the cosmetic problems that may accompany the unbalanced facial growth. Both jaws can be moved simultaneously if necessary. Additional procedures such as chin contouring, neck liposuction, rhinoplasty, or other cosmetic procedures can also be performed at the same time, if desired.
In almost all cases the bite is off far enough that orthodontic treatment is required before surgery can be performed. The orthodontist will review the treatment options with you and explain how long you will need to wear the braces prior to surgery. Usually it will be less than one year. The orthodontic treatment is designed to align the teeth for the best bite after surgery. Therefore the bite may seem to get worse while you prepare for surgery. Once the orthodontist has the teeth aligned properly, surgery may be performed.
We will coordinate all treatment with your orthodontist and general dentist. This is a team treatment, which requires input from each participant.
Summary of Treatment
Prior to surgery, the treatment options will be reviewed and the final treatment plan established with the patient. Facial measurements, x-rays and photographs are analyzed to determine the best treatment. Computer imaging can be helpful to show the patient the appearance changes that may occur with various procedures. This will help the surgeon and the patient to select the desired procedure and give the patient an understanding of the proposed cosmetic improvements with the selected procedures.
Jaw repositioning surgery may be performed in the hospital, a day surgery center, or an office surgical facility. We have a surgical facility in our office that permits us to perform many of these procedures on an outpatient basis. Regardless of the facility, patients come in on the morning of surgery. Surgery is performed under general anesthesia and a long lasting local anesthetic is administered to maintain comfort during recovery. Usually, if only one jaw is being moved, patients go home on the same day.
Our office is located in a professional building, which is connected to Medical City Hospital. When surgery is performed on both jaws in our office surgical facility, the patient will spend about two hours in our office recovery area, and they will then be transported to a room down the hall in Medical City Hospital for 23-hour observation. If both jaws have been moved, patients usually spend the night in the hospital and go home the next morning.
The Surgical Procedure
Upper jaw surgery is performed through an incision in the gum tissue above the upper teeth. The bone around the upper jaw is cut with a fine surgical saw. This loosens the jaw so it can be gently moved forward or backward. This procedure is called a LeFort I osteotomy. Additional bone is removed if the upper jaw is to be shortened, as it would need to be to correct Long Face Syndrome problems. Bone can be added if necessary to lower the jaw and make it longer as it would need to be to correct Short Face Syndrome problems. The jaw can be rotated right or left to correct an asymmetry, or divided into segments to widen the jaw. The upper and lower jaws are held together in the best bite, and tiny titanium plates and screws are used to secure the jaw in the final position. The bones heal together and the jaw returns to normal strength. Dissolving stitches are used to close the incision.
Lower jaw surgery is performed through incisions in the mouth where the wisdom teeth usually come in. The bone is cut in a front to back direction and splits so the two pieces can slide along each other and still overlap. This is called a Sagittal Split osteotomy. The part of the lower jaw with the teeth is moved forward or backward as needed to obtain the desired bite and appearance. A very small incision is made in the skin of the cheek, so that holes can be drilled through the overlapping bones. Small titanium screws are placed to hold the bones together as they heal to normal strength. Dissolving stitches are used to close the incisions.
Both jaws can be moved at the same time. Additional procedures are frequently performed to improve breathing through the nose, or to contour the chin for better appearance and reduced muscle strain. Patients will spend about one hour in the recovery room and then return to their hospital room until ready to go home.
Because we always use the bone plates and screws, rather than just wires, to align and stabilize the jaw, it has not been necessary to keep the teeth wired together after surgery. Immediately after surgery patients are able to open their mouths to talk, eat and drink. They will usually only open about half of normal for a few weeks due to tightness in the chewing muscles. Patients must remain on a very soft diet for about one month to permit the bones to heal before returning to a normal diet. If the upper jaw is moved, there is usually stuffiness in the nose, a post-nasal drip, temporary numbness in the upper lip and cheeks, and swelling in the cheeks. If the lower jaw is moved, there is soreness and swelling in the jaw angle area, and temporary numbness in the lower lip and chin. Patients usually have a sore throat for a short time, and mild to moderate discomfort for a few days. Patients are usually able to return to work in one to two weeks, depending on the number of procedures performed.
The orthodontic treatment resumes a few weeks after surgery to finalize the corrected bite. Usually the braces are removed about three to six months after surgery, or whenever the final bite has been established.
Insurance and Our Office Surgical Suite
Most patients do not have insurance coverage for orthognathic surgery. Therefore, we perform most orthognathic surgical procedures in our office surgical facility. We can keep the costs in our office much lower than the hospital, and thereby make it affordable for almost all patients.
We will assist our patients in determining if they have insurance coverage, the extent of the coverage, and we will help them to select the best treatment facility for their needs. If we are not on your insurance plan, we can provide the service on an out-of-network basis. In this situation, the patient will pay our charges and be reimbursed by the insurance plan. Your out of pocket expenses will vary depending on your insurance plan, the surgery performed, and the facility where the procedure is performed.
The same techniques for anesthesia and surgery are used in both the office and hospital. In the office, we will use an anesthesiologist or nurse anesthetist based on the patient’s preference. If the patient has insurance coverage, we will usually perform the surgery in the hospital to obtain the best insurance benefits.