Orthognathic Surgery

What is Orthognathic Surgery?

The word "Ortho" means straight and "gnathic" represents those aspects pertaining to the jaws. Hence, Orthognathic Surgery means straightening of the jaw(s) by surgery. An Oral & Maxillofacial Surgeon carries this out. It is a cosmetic surgery and the surgeon envisages changing the face of a person from distortion to proportion. Orthognathic Surgery is sometimes called “Surgical Orthodontics” because just as an orthodontist repositions the teeth with the help of braces within the oral cavity, the Oral & Maxillofacial Surgeon repositions one or more jaws (skeletal bones) through surgical procedures to produce a much more pleasing appearance and also improved ability to chew, speak and breathe. The main objective of Orthognathic Surgery is the correction of a wide range of minor and major facial and skeletal (jaw) irregularities. The shape of the face depends on the architectural framework of the facial skeleton. Through Orthognathic Surgery the surgeon could reposition the bones of the face and the jaws to a more aesthetically acceptable position.

Who needs Orthognathic Surgery?

Jaw growth is a slow and gradual process which should proceed in a systematic and sequential manner. However, in some instances, the jaws (upper and / or lower) may grow at different rates, deviating from the normal. This causes many functional, cosmetic and psychological problems. Injuries to the jaws at a young age or during birth (delivery),  birth defects etc. also contributes to abnormal growth patterns and positioning of the jaws. While Orthodontic treatment (braces) can correct problems associated with malaligned teeth, Orthognathic Surgery is essential if the jaw bones need repositioning. The results of orthognathic surgery will be very often dramatic and will result in positive effects in several ways in the life of the patients.

The common Maxillofacial deformities and their clinical appearances are the following:

   1. Protruded Maxilla (upper jaw): The upper jaw is protruded beyond the normal limits along with the teeth. The person cannot close his lips (lip incompetence) without effort. The teeth are always visible and in most cases the whole of the gums are visible on smiling (gummy smile). A gummy smile is mainly due to the vertical excess of the maxilla.

   2. Retruded Maxilla: This deformity is due to under development of the upper jaw mainly seen in people who have cleft lip or palate. After the surgical correction of the cleft lip or palate at a young age the growth of the maxilla is retarded along with displacement or destruction of the tooth bud. This results in a dish shaped face with a hooked or flaring nose and irregularly aligned, rotated or missing teeth.

   3. Protruded Mandible (lower jaw): In some people there will be extra growth of the lower jaw resulting in long jaw. Their faces are very long with protrusion of the lower teeth and thick lips. Normally on biting the lower teeth will be inside the upper teeth while in people with long jaws usually the lower teeth will be outside the upper arch.

   4. Retruded Mandible: In some people due to developmental deformity or due to hereditary factors the lower jaw is very small resulting in a “bird face”. There is no proper development of the chin.

   5. Facial Asymmetry: Sometimes a part of the face maybe overdeveloped or underdeveloped causing one part of the face to be small or large. One side of the face is not in symmetry with the other side giving an unaesthetic appearance.

   6. Ankylosis of Tempromandibular Joint (TMJ): Injury during birth or trauma or infection at a young age to the tempromandibular joint will result in restricted mouth opening and reduced growth of the mandible.

   7. Nasal Deformity: Nasal deformities are often seen along with deformities of the jaw. Some common deformities of the nose are: deviated nasal septum, flared or constricted ala of the nose, saddle nose, hooked nose, asymmetrical nose, etc.

At what age can Orthognathic Surgery be done?

The ideal age for Orthognathic Surgery is after the growth period has been completed. After 18 years for girls and 20 years for boys. Ankylosis of the TMJ is an exception. For this condition, the surgery should be done as early as possible to rehabilitate function and growth of the mandible. If the patient has got psychological problems due to the deformity of the face then the other orthognathic surgeries may be taken up at an earlier age.

What are the preparatory steps for the surgery?

Patients are clinically examined in a thorough manner based on certain protocols. Patient case files, Xrays, photographs and study models are prepared to clearly document as well as understand the nature of the deformity the patient. These records also help plan the surgical procedures. Once the planning is done, the surgeons discuss the treatment plan with the patient and his/her close relatives. All doubts / clarifications concerning the surgery are taken up for discussion in order to allay the fears of the patients as well as relatives.

Pre-surgical orthodontics (braces) is commenced for the patient in order to move teeth to certain positions in order to facilitate a smooth and effective surgical procedure. Once, the pre-surgical orthodontic procedures are completed, the patient is posted to be taken up for surgery at the hospital, under general anesthesia.

The normal protocol for any major surgery under general anesthesia is followed in these cases such as,  basic blood and urine investigations, screening of the patient by a physician and an anesthesiologist in order to assess his/her fitness for anesthesia. The patient is normally admitted on the previous day of the surgery and also put on certain diet restrictions and pre-surgery medicines.

What is nature of the post-surgical care to be taken?

Immediately after surgery the patient will be shifted to the recovery room until the general anesthesia has worn off. The patient may be kept in the ICU (intensive care unit) for 24 hours to monitor the vital signs. Family members are allowed to see the patient for a short period of time. An Intravenous (IV) line to the arm will be used to provide the required medications and nutrients, until the patient is able to take sufficient food by mouth. Elastic bandages may be placed over the face to reduce the swelling. Minor bleeding maybe seen after the surgery. If surgery of the maxilla (midface) has been done then there can be oozing of blood from the nose, which will normally stop within 24 hours.
Patients can expect temporary swelling of the lips, cheeks and nose. This is a normal healing response and will disappear after a week or so. Patients will experience nasal congestion and sore throat due to nasal tubes used for general anesthesia. Patients may also have vomiting or nauseating sensation due to the medications used. After been shifted to the hospital room, the patient will be put on a soft diet, as chewing food will be difficult in the initial stages. In some cases the jaws maybe immobilized with wires and patients can take only a liquid diet in such situations.

Oral Hygiene has to be maintained meticulously by the patients. Brushing of teeth and tongue cleaning are of utmost importance in maintenance of oral hygiene. Initially we recommend baby toothbrushes even for adults in the post surgical phase. Brushing and tongue cleaning should be done looking into a mirror so that the area being cleaned can be visualized, to avoid damaging / clinging of tooth brush bristles to the orthodontic brackets and bands inside the mouth. A mouthwash will be recommended and will have to be used without fail as per prescription. Poor oral hygiene will result in infection, a bad taste in the mouth and increased swelling of the face.

You will have to stay at the hospital for a week or more, till you have recovered from your surgery. After going back home you can return to work or college/school as soon as you feel like comfortable. It is preferable for patients to take rest for 2-3 weeks. Appearance of patients can change considerably (for the better, of course) and therefore, patients should be prepared for signs of surprise from your family members and friends as they see you after recovery from the post surgical swelling. But it won't take long for them to adjust to the "new person".

The initial healing will take 6 weeks but the completion of healing process will take up to 9-12 months. During this period, the patient has to visit the surgeon and the orthodontist on regular intervals as advised. Throughout this period, oral hygiene has to be maintained meticulously. In most cases the orthodontic braces are removed after 6-8 months following surgery. If plates have been used for the surgery, another short surgical procedure may be required within a period of 6 months, for plate removal. However, there are cases where the plates are not removed at all. Absorbable plates are also being used these days in order to eliminate the requirement of the second surgery.

What are the Complications of Orthognathic Surgery?

Complications seen in any major surgery under general anesthesia maybe seen in orthognathic surgery. Swelling, pain, nausea, vomiting, bleeding, infection, chest infections, etc are some of the potential risks of any major surgery under general anesthesia. Other complications specific to orthognathic surgery are:

* Loss of sensation resulting in numbness or tingling sensation of the chin, cheek, nose or tongue may occur after surgery. Sensation returns to the affected areas as the nerve fibers regenerate and mend themselves, after a few months of surgery. Rarely some individuals may experience permanent altered sensation.
* Sinus complications such as sinusitis may occur after surgeries of the maxilla. This may not require any further treatment as it  usually gets corrected on its own within a limited period of time.
* Nonvitality of teeth near the osteotomy (bone-cutting) sites are seen rarely. This may necessitate root canal treatment of the involved tooth / teeth at a later date.
* Relapse or unpredicted shifting of the new jaw position occur uncommonly. If it does then further surgical intervention would be necessary.
* Periodontal infections around the teeth near the osteotomy site may cause mobility of the concerned teeth. This may be corrected by periodontal flap surgery and bone graft.
* Necrosis of bone is seen very very rarely. This could be due to reduced blood supply to the area and will require surgical removal of the infected bone.
* Unrealistic expectations by the individual will result in dissatisfaction of the "new" face. Some individuals imagine and attribute all their psychological problems to their facial deformity and will not be satisfied even if good results are achieved. After all, the surgeon is only a human being, he only tries to correct or repair what you already have, and every surgery has its own limitations. Individual satisfaction is very subjective and a positive attitude from the parents and their relatives are very essential.