Orthognathic (Jaw) Surgery
What is it?
Orthognathic surgery refers to repositioning the upper jaw (maxilla), the lower jaw (mandible) or both jaws to make sure that they fit together in the proper way and that your teeth are aligned (occlusion). The goals of the surgery are to make you eat/chew better, breathe better, and even speak better. Additionally, if your jaws are not aligned properly, it often influences the way that you look. Surgery can improve your profile and the harmony of your features, as well as the way your nose and lips look. You may be born with uneven jaws, or it could be the result of trauma or uneven growth related to other medical problems (such as cleft lip and palate). Minor differences can often be corrected with orthodontics. Larger differences usually require surgery to fix. In most of these instances, surgery is recommended because the patient has symptoms which are treatable and quality of life can be improved. For example, when the teeth do not fit together properly it can be difficult and painful to chew, and this may limit the types of foods you are able to eat and cause problems with your teeth. Sometimes jaw asymmetry can also cause a problem with speech. If there is not enough room in your mouth for your tongue to form words against your front teeth, it may be difficult to understand what you say. This can affect your job as well as your social life. Additionally, if you have a small lower jaw, it can be more likely for your airway to collapse or become obstructed by your tongue, especially while you sleep. This is called obstructive sleep apnea. All of these problems can be effectively treated by jaw surgery. If you need corrective jaw surgery in Houston, visit us at Lift Plastic Surgery.
Often you will be referred to us by either your orthodontist or your ENT physician.
There are two general patterns of abnormal jaw relationships with multiple other variations in between. The first is class III malocclusion or “underbite”. These patients generally need their upper jaw moved forward so that the upper teeth fit over the lower teeth. If the distance that the jaw needs to be moved is close to or greater than a centimeter, sometimes the lower jaw needs to be moved as well, or something called “distraction” will be needed. The other category is class II malocclusion or “overbite”. These patients generally need their lower jaw moved forward. If the lower jaw is small, it is often beneficial to also move the chin forward to balance out the profile and proportions of the face (see the section on genioplasty). Ideal results are obtained by combining your jaw surgery with orthodontics, and we will work closely with your orthodontist to come up with a treatment plan. Many patients will need braces before they have surgery, and the braces are also a useful tool for us in the operating room to keep your jaws aligned. When we see you in the office, we will come up with a detailed treatment plan depending on your specific needs.
What happens during surgery?
Before the day of surgery, we take special x-rays as well as impressions of your teeth, and plan the exact movements that we will perform and final positions of your jaw. During surgery, you will be under general anesthesia with the breathing tube placed in your nose so that we can check how your jaws fit together. Incisions are made all on the inside of your mouth, and the tissues are lifted off of the bone in the area where we are working. In order to move the bones, we have to cut them with a saw in different ways depending on the surgical plan, and release them from surrounding tissue. Once the bones are free we move them into their new position and fix them there with metal plates and screws. Then we check the alignment of your bite and close the incisions with absorbable sutures. Rarely, with certain procedures of the lower jaw, you may need to have your jaw wired shut for several weeks. You will stay in the hospital until your pain is controlled, usually at least overnight.
What will my recovery be like?
Once you go home you will be able to shower. You will be sent home with pain medication and antibiotics. You will have to stick to a soft diet for at least three weeks depending on how you are healing. Expect that you will have bruising and swelling after surgery, and possibly some numbness of the lower lip, chin and cheeks due to nerves in the area of the surgery that can become irritated. You will have incisions in your mouth so you will have to be careful brushing your teeth, and will have to use a special mouth wash three times a day and after eating. Swelling will be significantly improved after a week, but may take several weeks to months to completely resolve. If you have numbness, this may take months to gradually resolve, but is rarely permanent. You will also need to minimize exercise or vigorous activity for 4-6 weeks after surgery to allow for proper healing and to prevent bleeding and worsening of swelling. You should plan for activities accordingly. Sutures in the mouth will dissolve on their own.
What are the risks?
There are large sensory nerves that exit the bones in the areas that we operate on. It is possible for these nerves to become irritated or injured by the surgery which can cause numbness to these areas. Usually this is not permanent, but may take several months to slowly resolve.
It is usually not possible for us to make your bite completely perfect at the time of surgery, so you will generally need some minor adjustments by your orthodontist afterwards. Any time we move the bones there is always the possibility, though small, that they may not heal correctly which would require additional surgery to fix. The plates and screws that we place during surgery are meant to be permanent. However, it is possible that they could become infected. Should this happen, they would need to be removed.
What is obstructive sleep apnea (OSA)?
OSA occurs when there is blockage of your airway while you sleep, making it hard for you to breathe. This actually decreases the amount of oxygen that you are able to take in and has multiple deleterious effects on your body over time. Additionally, this process disrupts the normal sleep pattern causing excessive daytime fatigue. OSA can have several different causes that affect the way it is managed. In most cases, however, a CPAP (continuous positive airway pressure) machine is prescribed. The machine works by pumping a continuous flow of air through a mask worn over the face. This helps push the airway open so that you breathe more normally. CPAP is very effective, but there are many patients who do not use it because it is noisy and uncomfortable. If this is the case for you, you may want to consider a surgical option. An ideal surgical candidate has failed conservative treatment (CPAP, mandibular advancement device/splint), has a craniofacial deformity such as a small lower jaw, has a BMI < 30, is less than 50 years old, and has moderate to severe obstructive sleep apnea. Not every patient fits into the “ideal” patient categories listed above. Jaw surgery is still considered one of the most effective and safe upper airway surgeries for heavier patients with moderate to severe sleep apnea that have failed conservative treatment, who have had previous upper airway surgery, and are > 50 years old. This is because surgery seems to result in the greatest overall reduction in apnea-hypoxia index(AHI) compared with other upper airway surgeries, so even more difficult patients can qualify. The procedure allows patients to be free and clear from CPAP machines while improving sleep, breathing, energy, and overall medical health and life span!
What is distraction?
Distraction osteogenesis is a technique used when bones need to move a far distance, usually greater than a centimeter. At the time of surgery, the same cuts are made in the bone, but special hardware is applied that allows the bones to be slowly moved over time. This allows the body to start forming bone as the gap is created and also helps to stretch the overlying soft tissues. This results in better overall healing without the use of bone grafts, as well as a more durable result with less relapse. The hardware has “arms” on the outside of the body which are turned with a screwdriver twice a day, or “distracted”. Distraction moves the bone 1-2 mm per day and can last several days to weeks depending on the distance the bones need to travel. Often you will be able to do the distraction yourself at home. There are two different types of distraction hardware that are used. “Internal” devices are attached to the bones inside of the mouth and have a small arm that extends to the outside for turning. External devices, or the “HALO”, are like metal helmets that attach to the skull from the outside and keep the jaw stable while it is moving. Once distraction is done, the hardware stays in place for approximately 6 weeks to allow the bone to heal and become solid. We then bring you back to the operating room to remove the hardware in a second procedure.