Orthodontics &Orthognathic Surgery

How jaw surgery, in conjunction with orthodontics, can improve facial balance

Dr’s. Victoria Lynskey, Jerry Mogannam, & Vicente Chavez

• Greek: “Orthos”=straight “Gnathos”=jaws• Jaw surgery to reposition the jaws• Result: correct jaw alignment, occlusion and

facial harmony• Movement of the jaws forward or backward, up

or down, or rotated results in the movement of the facial soft tissue of the chin, cheeks, lips and tip of the nose

What is Orthognathic Surgery (OGS)?

Why would a patient need OGS?

• Function: Malocclusion impedes jaw function and does not allow proper chewing of food. This might exert negative influence on food digestion and overall body health.

• OH: crowding of teeth facilitates accumulation of food debris and aggravates maintenance of oral hygiene, therefore, teeth are more likely to be affected by dental caries or periodontal disease.

• Wear: Due to malocclusion teeth may wear out faster than usually and the lifetime of dental prostheses may shorten.

• Medical problems: extremely small lower jaw may result in snoring and sleep apnea, which can consequently cause many health problems. In cases of short upper lip and vertical excess of the upper jaw, the lips are usually open & it may stimulate undesirable mouth breathing which further worsens occlusion.

• TMJ: Frequently malocclusion can have strong negative effect on speech function and often it can be accompanied by jaw joint pain.

• Esthetics: occlusion and the position of jaws define the height of the lower third of the face to the greatest extent, hence the aesthetics of the facial profile as well. Convex ‘bird face’ or concave ‘mature face’ profiles are considered anesthetic, therefore severe anomalies can cause social problems if left untreated.

Patient Selection

• Malocclusion: Skeletal vs Dental • Severity of the skeletal malocclusion

– Orthodontic Camouflage– Ortho tx alone: use braces and appliances to align the

occlusion irrespective of the jaw position– Useful in borderline patients if surgery is not an option

• Age• Overall dental and medical health of patient• Psychosocial evaluation

Timing

• Patients from 18-45yo are the best candidates for OGS.

• We want jaws to be fully formed with no additional growth expected

• Before the age of 18, tx is limited to orthodontics and growth modification, however, if this is not effective, patients and parents must consent before set-up for OGS is initiated.

• Pre-surgical ortho may worsen the malocclusion and esthetics in order to improve the surgical movements

Malocclusion: Skeletal vs Dental• Dental: the jaw relationship is acceptable, but the teeth are

misaligned• Orthodontics may be simple alignment or more complex, including

growth modification appliances or extractions to improve facial harmony

• Mild orthodontic camouflage may be in order for borderline cases• Ortho alone is insufficient for successfully correcting skeletal

malocclusions when the chewing function and facial esthetics are desired in addition to occlusion

Orthodontic camouflage

• Ortho tx alone: use braces and appliances to align the occlusion irrespective of the jaw position

• Useful in borderline patients if surgery is not an option

Malocclusion: Skeletal• Skeletal: discrepancy in shape, size, and/or position of 1 or both jaws• For these patients, simple dental alignment provides little help as a

finished dental alignment will not result in occlusion because the jaws don’t match each other

• Often accompanied by an incorrect facial profile• Surgery on 1 or both jaws will correct the

– jaw position, – improve chewing function, – enhance facial features, – and reduce any airway related problems

• May be caused by genetic or environmental factors.

Types of Skeletal malocclusions:

• Evaluate the face in 3 dimensions

• Sagital, or A-P (Class II, III)

• Vertical (Open Bite/Deep bite

• Transverse (Jaw width discrepancies)

• Combination (including asymmetries)

MalocclusionSagital discrepancies: Class II

• Class II:– Small or retruded lower jaw, or anteriorly displaced upper jaw– Convex Facial profile– Airway: the airway may become tapered causing snoring and sleep

disorders– TMJ: Patients often try mask their distal bite by thrusting their lower

jaw forward. The so called “Sunday bite” may sometimes cause overstretching of the joint's ligaments which results in hypermobility of jaw's joints.

– Occlusal wear: Molars may be heavily worn due to cusp-to-cusp contact

MalocclusionSagital discrepancies: Class III

• Class III:– Lower front teeth are edge-to-edge or in front of the

upper front teeth. May be due to a small upper jaw, large lower jaw, or combination

– Facial profile: Concave profile with a protruding chin and receding mid-face

– Chewing: Normal if lower teeth are in front of upper, but may result is a shift if the front teeth are edge-to-edge

MalocclusionVertical discrepancies: Open Bite

• Open Bite: the molars are the only teeth to come into contact. Often due to the incorrect position or shape of the upper jaw, or the divergent growth profile of both jaws.

• Mouth breathers or habits contribute to this type of malocclusion

• Facial Profile: is usually convex and long, causing the lips to be strained when trying to keep the lips closed

MalocclusionVertical discrepancies: Deep Bite

• Deep Bite: The overlap of the front teeth is too big, and on some occasions, the upper front teeth may completely cover the lower front teeth. A deep bite is often the result of a small lower jaw and incorrectly aligned teeth.

• Facial Profile: convex and the lower third of the face is short. The upper lip may be either normal or protruding, whereas, the lower lip is curled with a deep fold above the chin.

• Airway: sometimes associated with a reduced airway especially if a patient has a small lower jaw.

Malocclusion: Transverse discrepancies: crossbite

• Occlusion. The upper molars positioned lingually more than the lower molars. Most often is caused by a narrow upper jaw In many cases, a cross bite is associated with mouth breathing.

• Facial profile: The cross bite is frequently associated with an open bite which results in a long and convex facial profile.

• Airway: The airway may be tapered and the patient may have snoring problems. Cross bite is diagnosed in children and adults who frequently keep their mouth open because of impaired nasal breathing.

Vertical discrepancies: Gummy Smile

• Vertical maxillary excess and or short upper lip• Gummy smile is an aesthetic consequence rather than a

malocclusion. It can be noticed in patients with either ideal or incorrect occlusion. When smiling, patients show a fair amount of gums in their upper front teeth which looks unattractive in most cases.

• Occlusion. Occlusion may vary• Facial profile. Usually the facial profile is convex and the lower

third of the face is long. Lips are strained when in the closed position.

Malocclusion: Transverse discrepancies: Brodie Bite (scissor bite)

• Occlusion. The lower molars are positioned lingually: SEVERELY. When the mouth is closed the molars miss each other and overlap with no contact. A possible reason for this is a naturally narrow lower dental arch or a hyper-expansion of the upper jaw

• Facial profile. The scissor bite has no significant influence on the facial profile. .

• Chewing function: The chewing function is bad since the molars make no contact with each other.

Malocclusion:Combination: Jaw asymmetry

• Face. The lower jaw body is longer on one side; so therefore, the chin obviously moved toward the shorter side. Horizontal asymmetry usually develops when the growth of one side of the lower jaw is accelerated. The cause for this growth acceleration is unknown.

• Occlusion. Usually there is a cross bite on one side of the jaw which has the tendency to develop into a mesial bite. The upper dental arch is often normal and may not be affected by the position and shape of the lower arch.

• Facial profile. The facial profile is usually concave.

Orthognathic treatmentOrthognathic treatment takes about two years to complete. Once begun, it is

seldom possible to reverse or switch to non-surgical treatment, so it is strongly recommended that the original treatment plan be completed once begun..

The course of treatment• Restorative/rehab: At the beginning of the treatment, teeth are restored

while, at the same time, useless teeth, as well as, the wisdom teeth are removed.

• Pre-surgical Ortho: The orthodontic treatment is started & it lasts for about 18 to 24 months.

• OGS: Then orthognathic surgery is performed on one or both jaws, followed then by the final orthodontic treatment which, in itself, lasts approximately 6 months.

• Post-surgical ortho: to finish the occlusion• Post-restorative: select teeth may receive restorations or crowns, or, dental

implants may be inserted and restored in edentulous areas • Smile: After all this is completed, the patient will enjoy and benefit from a

stunning smile and pleasing facial features.

Orthognathic treatment: Treatment Planning

Consultation• The team of doctors is compiled: Restorative, ortho, OMFS. The

occlusion and facial features are evaluated with photographs and measurements of the face and teeth. The purpose of this meeting is to collect all the information that is needed to compile a treatment plan. During this short consultation, general information about the problem, as well as, the possible solutions are disclosed to the patient. The individual treatment plan is then prepared during the following 1 to 2 weeks.

• Panoramic radiograph• Lateral ceph • P-A Ceph• Dental model casts.• Articulated models

Orthognathic treatment: Pre-surgical ortho

Pre-op ortho set-up• Preoperative orthodontic treatment takes from 9 to 18 months to complete. Braces

are bonded onto the teeth and remain throughout the entire treatment time. • The primary purpose is to align the teeth into well-formed arches that match each

other. • TeethWhy do patients need braces? • The varied size and poor position of the jaws often results in an incorrect shape of the

upper and lower dental arches. • During the many years of use, the dental arches adapt or compensate to fit each

other best, resulting in an incorrect position. • Orthodontic treatment will align the dental arches, but the occlusion and the facial

aesthetics become worse during this stage of treatment. In nearly all cases, orthodontic treatment is imperative since properly aligned dental arches are key for a stable and well-established postoperative result.

Model Surgery• When the preoperative orthodontic setup is finished, the position of the jaws is

registered with a face bow and the dental models are transferred to a an articulator. • A simulation of the operation, based on the specified plan, is performed and a special

splint is produced and adjusted. This splint is used during the surgery and is essential for correct and precise jaw positioning.

Mother

Son

15yo 20yo

Surgery

(I’m going to leave this up to the professionals )

• First day after the surgery. New occlusion is checked when the patient is fully awake.

• Massive facial swelling and bruises may appear during the first two days.

• Pain is easily controlled with pain-killers.

• Intensive antibiotic regimen is prescribed right after the surgery to protect the patient from infection.

• Chewing is not allowed after the surgery. One or several rubbers bands are applied on teeth to direct the jaws into correct position upon function. They are tight enough to keep the jaws in occlusion during rest but do not prevent a person from opening mouth slightly.

Orthognathic treatment: Surgical Recovery: Day 1-7

• One week after surgery. Facial swelling should be starting to resolve on the third or fourth day.

• The first postoperative visit should be done on the 6-7th day after surgery. Wounds and occlusion is checked, elastic rubber bands are readjusted if needed.

• 2 weeks post-surgery: Elastic rubber bands are also taken off for the first time, occlusion is rechecked. The patient is trained to brush teeth correctly and apply rubber bands according to the scheme provided by the doctor.

• 3 weeks post-surgery About 80% of swelling is gone by the end of the third week. Most of the swelling is gone in two months, however the residual swelling in cheek area may be felt by the patient as long as six months after surgery.

• Physical work is not recommended first month after surgery, however office work at home may be started right after discharge from the hospital.

Orthognathic treatment: Surgical Recovery: Weeks 2-8

Orthognathic treatmentFinal ortho treatment

• Takes approximately 6-9 months.• When the jaws have fully healed up the orthodontist has to correct

the position of individual teeth. This is needed for a stable treatment result.

• Active post-operative orthodontic treatment can be started two to four months after surgery. Before that time healing process is not complete and attempts to correct the position of teeth or modify the occlusion may have a negative effect on the overall recovery.

• Orthodontic treatment is finished when the occlusion is stable and teeth come into correct contact. At the end of the treatment the braces are removed but the patient still needs to wear retainers.

• After debanding, the teeth are checked and treated if needed. Some patients may need dental implants or crowns and bridges to restore dentition and finalize treatment.

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