Jaw Surgery

ORTHOGNATHIC or JAW SURGERY  

The operation of orthognathic surgery is mostly to correct the results of abnormal growth of the jaws.  complaints the patients have include :

Jaws too big or too small 

Difficulty in chewing and eating .Rarely this placing   stress on the jaw joints. 

Gap between the teeth.

Gummy smile.

Biting on the palate or abnormal wear of teeth

Causes of misaligned jaws

 In most young people, the upper jaw grows proportionate to the lower jaw. In some, however, the upper jaw may grow too much in height resulting in excessive show of upper teeth and inflamed gum.  Alternatively it may not grow forward enough, making it appear as if the lower jaw is too large and nose base flat.

Similarly the lower jaw can grow too much, producing a prominent jaw or not enough, giving the appearance of a weak jaw and chin.

 Occasionally the growth is asymmetrical, that is one side of the face grows differently to the other.  Sometimes the differences between the growth from the average, is due to cleft lip and palate.

Why treatment is sometimes carried out?

 The main aim of such operations is to improve the function of the jaws.  Chewing becomes easier, but in some people also, there are beneficial affects on speech and in rare cases also, in breathing at night.  With improved function, there is also improvement in appearance .This often manifests as more self confidence.     

Initial Assessment 

Patients are seen in Joint Clinics with Orthodontic colleagues.  Patient’s main complaints are recorded and medical and dental history taken. 

Special tests

X-rays are taken of the jaws, and impression of teeth taken to make models of the jaws and teeth.

The x-rays allow measurement of many features of the face and their comparison with others of the same sex and race.

Treatment is so planned   so that the jaws are in their ideal position compared to the rest of the face .and the teeth meet correctly.    

Visual assessments and computer programs determine on the best type of orthodontic treatment and surgery.   

  TOP OF PAGE 

Orthodontic  and surgical treatment .

Orthodontic treatment may take one to two years and is through brackets glued to teeth (train tract braces).  

The teeth are moved gently into their correct position and inclination so that they slot together as much as possible at the subsequent operation.

 The proposed changes   are initially carried out on plaster models and the movements which are necessary measured. A splint (wafer) is made by the Maxillofacial technician to guide  the surgeon  to achieve the correct final positioning of the teeth and jaws. Such splints are kept in place for about a week after surgery.

Surgery involves a hospital admission and the operation takes anything between one and a half to seven hours, depending on its complexity.  The patient stays in hospital for a few days and is away from school/work for a few weeks afterwards.   Most of the procedures are carried out from inside the mouth so there is minimal surface scarring.  

Like any operation, such surgery carries complications, the main one in the lower jaw is subsequent numbness of the lip.  In most young patients this improves, though in adults this may be a bigger problem. The usual warnings given are 

  TOP OF PAGE 

Soon after the operation 

Swelling - the body needs to bring into the site of the surgery many cells and other substances necessary for good healing.  This results in swelling.  Sometimes this is quite impressive but there is no need for concern, it does not mean any infection.

Oozing - there are lots of separated bone surfaces which can ooze blood .This gets mixed up with increased salivation and very often has to be sucked out.  

Nasal Tubes  -Following an upper jaw (Le Fort 1) osteotomy operation ,the nose is quite often blocked. One tube is  placed in the nose when you are under general anaesthetic to help with the breathing .Another  narrow tube leads to the stomach so that if required it can be used to empty it of any  swallowed   blood . 

Special Nurse/ ITU   -  Usually patients have one-to-one nursing for the first day or so, however, if such a nurse is not available, then patients are often looked after in the intensive therapy unit (ITU) where more unwell patients are cared for.

If Pain or Nausea -  if you have any significant pain then please let the nurses know, they can give you the prescribed medication to reduce your pain.  Similarly if you are nauseated, please inform us so that the appropriate tablets can be given.

Jaws Fixed Elastics  -  having re-positioned the jaws the bone segments  are  fixed firmly with plates. Elastics are used at the end of operation to keep the upper and lower jaw together.  These tear easily they are simply, therefore, for comfort and to reduce the tendency of the muscles pulling the jaws into the wrong position.

Cuts on Skin  -  occasionally some of the plating needs small cuts on the skin of the cheek.  These usually heal well leaving no mark.

Angle of Mouth Abrasion  -although the work is done through the mouth the corners can get rubbed and become sore.  We give you creams to apply to make the area more comfortable.

Blood Loss - attempts are made to reduce the bleeding by reducing the blood pressure as well as using local anaesthetic.  However, occasionally there is sufficient blood loss that the anaesthetist feels it is in your best interest to have some blood, which is specially prepared for you.  This may be given over the next few hours.

Not talk and smile  -  it is difficult to speak for the first few days and, therefore, it is sensible to have a little booklet in which you can jot down your questions and comments.                                            

HOME

 

Later

Swelling. This can continue to increase for a few days and is no need for concern. You nay be given medications to prevent it from becoming excessive                                                           

Elastics  -  elastics will be kept in place for about a week, until the orthodontist is      happy that the jaw relationship is stable. 

Blood Tests  - most patients become a little anaemic and so it is best to assess the level of your haemoglobin. Most healthy young people can make more blood naturally over the next few weeks. You are given some iron supplements  and vitamins to help you with this.

Numbness Upper Jaw  -  in operations on the upper jaw the upper teeth and gum always feel numb initially, but this settles down in time.

Numbness Lips/Cheeks/Tongue/Chin -  one of the main problems with the lower jaw operation is the numbness of the lip.  The nerve which supplies sensation to the lip is within the site of the surgery and, even just gentle bruising or pressure on the nerve can make it go numb.  In the majority of patients however sensation returns  to normal. In rare cases there is persistent numbness.

Feel Tired - Want to go Home - any surgery makes you tired and, quite often patients feel a little depressed , This is a  healthy instinct to help you rest and deter you from excess  physical   activities.  So do not be surprised at your lack of energy.

Postoperative X-rays - we  often check the new position of the jaws with an x-ray.

Rarely re-operation  - rarely the jaw can slip in one position and patients can be taken back to theatre for a short operation, in which the plates are loosened, re-positioned and tightened.

Eating and Diet  -  it is very important to drink as much as possible.  Good healing also needs good nutrition and you are often seen by a dietician, who prescribes you the correct diet, including cartons of liquid food such as Ensure Plus.  Try different varieties to see which one you prefer.

Oops. Occasionally the Hospital caterers do not appreciate that your jaws are fixed together with elastics and that you cannot chew. If they send you a tasty solid meal , on request  it will be replaced by a more appropriate one. Sorry !!!

Facial Appearance Change  -  remember that the jaw relationship has changed and it has an effect on the shape of the nose and the chin. Upper jaw  brought  forward can lift up the tip of the nose and slightly broaden the base

Obviously because of the swelling, the appearance after surgery  is quite different to pre-surgery.  Do not be concerned about this, it does settle down.

Jaw Joint Dysfunction - good jaw relationship is best for the function of the jaw joints, however, at least in the initial phases, many patients have problems with pain around the jaw joints and, possibly, clicking.

Relapse  -  there is a tendency for the jaws to move backwards to the position pre-operatively and it is important to be monitored regularly by the orthodontists.

Occasional Need for Removal of Plates - sometimes the plates become infected and they have to be removed.  This usually has no impact on the position of the jaws; however, it requires a further operation.  

There may be further information, particular to your case, which your surgeon will discuss with you.

HOME

---

---

  TOP OF PAGE 

 

TYPES  OF SURGERY

There are two main types of operation.  

The one for the upper jaw is called Le Fort 1 osteotomy.  The work is carried out from inside the mouth, the bony part of the upper jaw is separated but the segment remains attached for its blood supply to the flesh through the back of the jaw.  That  loose segment can then be brought upwards (for patients with a gummy smile) .Or alternatively  brought forwards to improve the relation to the lower jaw or, even brought down so that more teeth are shown on talking and smiling .

The main lower jaw (mandible) operation is called Obwegeser sagittal split osteotomy.  Once again the operation is carried out from inside the mouth and the segment of the jaw, which carries the teeth, is separated from the back part which is attached to the jaw joint.  The lower part can then be either brought forward  if required or, pushed back, depending on the needs of the patient.  Guided by the wafer, the jaw is stabilized in its new position using miniature titanium plates.  After the operation, elastic bands are used to keep the jaws together in their new relationship until the healing is more advanced.

Swelling  This can sometimes be quite impressive, but is of no need for concern.  

Bleeding  As there are a number of raw surfaces it is usual, for a few hours at least, for the saliva to be stained with blood. Occasionally a patient may need to have a blood transfusion because of the loss of blood during the operation but, efforts are made to avoid this.

The main  long-term problem is the numbness of the lip and, occasionally, the tendency for the jaws to move from their position at operation.  For instance, a lower jaw, which has been pulled forwards, may go back a little. Before discharge, patients are seen and advised on their diet as, clearly, no chewing is possible in the immediate postoperative period and, patients should remain on a liquid diet.

There are a number of other operations available, which are chosen for specific cases with specific problems. 

   A much more exciting development, which is most suitable for the treatment of severe cases often  related to congenital abnormalities of the face

Early in the 20th Century investigators noted that  leg bones and its  flesh could be lengthened by gradually pulling the  segments  apart.

 This  principal as used in lengthening parts of the face ,    The jaw is cut  at a predetermined area but, before the healing takes place the front part  is pulled forward by use of sophisticated  multi-directional  distracter  instruments,   This not only produces more bone in the desired location  but also more flesh.  

   Other benefits of this technique include shortened operating time and decreased bleeding and less damage to the nerve supplying sensation to the lip. This  type of treatment is available only in some Maxillofacial Units.