Jaw Surgery (Orthognathic Surgery) Washington DC

Dr. Baker has dental, medical, maxillofacial, plastic surgery, and craniofacial training. He is one of a select few surgeons in the world with this type of expertise in the treatment of malocclusions with jaw surgery. He has lectured internationally, and nationally as well as published articles, chapters, and textbooks on jaw surgery. He is known as a leader in the field of jaw surgery and is on the faculty of many courses teaching jaw surgery techniques to other professionals.  The material below is intended to orient you to the role of jaw surgery in correcting malocclusions.  Any further questions will be addressed by Dr. Baker at the consultation.

Introduction

People today usually recognize irregular teeth or obvious jaw abnormalities and seek treatment from an orthodontist, who can improve tooth alignment, function, and facial esthetics. More severe malocclusions that require a combination of orthodontics and surgery for correction are called dentofacial deformities. These conditions can affect physical orofacial function in several ways. Chewing can be impaired, and especially in severe cases, this impairment can affect digestion and general nutritional health. Lip incompetence (lip separation in a resting posture) due to a long upper jaw results in mouth breathing, which eliminates the ability of the nose to breath properly. Speech is often affected by jaw abnormalities despite adaptive capabilities of the body. Irregular teeth may have a profound effect on maintaining proper oral hygiene and thus make teeth more susceptible to cavities and gum disease. Normal temporomandibular (jaw joint) function is also often affected by several types of dentofacial deformities.

The physical effects of a jaw malalignment are important, but the psychosocial impact of a dentofacial deformity on an individual is often paramount. Such a deformity can profoundly affect the quality of life and entail lifelong adjustment.

The combination of surgery and orthodontic treatment makes it possible to treat jaw abnormalities that previously could not have been corrected orthodontically (eg, long upper jaw and a bite in which the front teeth do not come together). Jaw surgery has created new and exciting opportunities in the treatment of patients with dentofacial deformities and has relieved the orthodontist of having only compromised treatment to offer patients with skeletal disharmony.

Three kinds of treatment are available when malocclusion is caused by severe skeletal discrepancies:

1. Growth modification. In growing children, dentofacial orthopedics (headgear, etc.) can nonsurgically modify jaw position to some extent if done early.
2. Orthodontic camouflage. Trying to correct a malocclusion that requires jaw surgery by only moving the teeth not only can compromise or even impair the esthetics but also can jeopardize the stability of the results. This option may also increase the treatment time.
3. Orthognathic surgery. Combined orthodontic and surgical correction is considered the best treatment modality for dentoskeletal imbalances once growth has ceased.

Treatment Objectives in Orthognathic surgery

Three treatment objectives are fundamental in orthognathic surgery: function, esthetics, and stability. These three objectives form the basis of goals in treating patients with dentofacial deformities and often go hand in hand.

Function

Functional and esthetic deformities often exist concurrently; when they do, treatment should be designed to correct both. When correcting a functional problem, the clinician has the opportunity to improve facial esthetics at the same time and should make full use of it.  Given that the jaws are going to be moved anyway, it is important to move them into the best aesthetic position that will correct the bite. The treatment of patients with poor function but good esthetics is particularly challenging. In these cases careful planning must avoid worsening the esthetics while providing optimal functional relationships.

Esthetics

Facial appearance is often the patient's main concern. It is the patient's perception of what is esthetically wrong that is paramount, and one of the clinician's first tasks is to establish the patient's esthetic concerns.

Because the orthodontic placement of the teeth dictates the surgical movement and, ultimately, the facial changes, the practitioner must carefully assess patients with musculoskeletal deformities before the commencement of orthodontic treatment. Accurate preoperative orthodontic and surgical planning that considers the indicated surgical movement is necessary to ensure not only good functional results but an optimal esthetic outcome as well. Dr. Baker’s training as an oral and maxillofacial surgeon equips him with the technical skill to perform the surgery, but it is his experience as a plastic surgeon that provides him with the expertise to envision the jaw movements that will produce the optimal aesthetic result for the patient at the time of surgery and as the patient matures. It is not uncommon to combine jaw surgery with chin surgery, nose surgery, or fat grafting to achieve the patient’s goals.

Stability

Without stability, the achievement of good function and pleasing esthetics is obviously not acceptable. Certain orthodontic tooth movements have questionable stability. An example is the extrusion of teeth to correct a skeletal anterior open bite; any preoperative orthodontic attempt to correct this type of open bite adds significant instability to the overall result. After surgical repositioning of the jaws beyond their biologic parameters, they will relapse into a more harmonious musculoskeletal relationship for the individual. It has been shown that the use of sound orthodontic mechanics and surgical techniques will produce optimal stability, function, and esthetics. Accurate treatment planning and meticulous orthodontic and surgical practice are essential to the achievement of treatment objectives. Just as important, however, is communication between clinician and patient, as well as between clinician and clinician.

First orthodontic consultation

Because people with irregular teeth and a jaw deformity usually seek treatment from an orthodontist, it is usually the orthodontist's task, at the initial consultation, to discuss the possible need for a surgical procedure as part of the treatment to achieve optimal results. During the first orthodontic consultation, a clinical examination is done and the appropriate records obtained. The records may be duplicated for the benefit of the surgeon. It is important for the patient to have the surgical treatment option explained to them prior to undergoing orthodontics because the direction the orthodontist moves the teeth for surgical treatment is usually in the opposite direction that he or she would move the teeth for nonsurgical orthodontic treatment. It can add many months or even years to orthodontics if the patient decides to have surgery after a nonsurgical plan has been initiated.

Definitive orthodontic consultation

The final pretreatment consultation takes place only after a systematic patient evaluation has been conducted and the orthodontist and surgeon have agreed on a final treatment plan. It is mandatory that the patient (and perhaps the parents or spouse) be well informed. Well informed patients follow instructions and, as a general rule, are easy to treat.

Dr. Baker makes every effort to explain if surgery is necessary, what the advantages and disadvantages are with or without surgery, what is entailed in surgery, and what can be expected during the preoperative and postoperative periods. Risks and complications are also discussed with the patient. Finally, a Powerpoint presentation is reviewed that shows typical results as well as a diagrammatic representation of the surgical procedure. Dr. Baker takes pride in informing his patients and gaining their confidence. Dr. Baker will keep explanations simple and use the your radiographs and dental casts to demonstrate the problems. Solutions for the problems will be discussed in general terms and the need for surgery explained. The importance of preoperative alignment of the teeth and the possibility of the bite not improving or even getting worse during this phase is explained to the patient.

Treated cases with similar problems will be used to demonstrate specific treatment objectives. For most patients the treatment time is extremely important, but it is preferable not to give a specific length of time. It is important, however, to give you a general idea of the length of treatment and a treatment profile explaining various phases of the treatment, the sequence of the stages, and the time each phase could take. You will be alerted to factors-such as bone density, periodontal disease, patient cooperation, age, and tooth extractions-that might influence the treatment time and surgical precision.

Explanation of typical treatment profile

A typical treatment profile consists of six stages:

1. Placement of orthodontic bands on the teeth. Any necessary extraction of teeth (including third molars) is done at this stage, and usually 2 or 3 weeks later the orthodontic bands are fitted.
2. Preoperative/preparatory orthodontic phase (9 to 18 months, on average). The teeth will now be aligned in their optimal positions in each arch. When the orthodontist is satisfied that this preparation is complete, the patient is referred back to the surgeon.
3. Surgical phase and healing time (4 to 6 weeks). Dr. Baker will surgically reposition the jaw or jaws into their most favorable relationship to establish a good occlusion (bite) and balanced facial proportions. After a short healing period, the patient returns to the orthodontist for the final correction of the bite. It is very important that the patient see the orthodontist 2 to 3 weeks after surgery for postoperative orthodontic control.
4. Postoperative orthodontic phase to perfect the bite (3 to 6 months). The purpose of orthodontics after the surgery is to refine the bite. It usually involves minor tooth movement to finalize the occlusion and achieve a satisfactory result.
5. Removal of orthodontic bands.
6. Retention phase (6 to 12 months). When orthodontic treatment has been completed, the teeth that have been moved through bone need to be stabilized in their new positions for a time. The orthodontist manufactures and fits a retention appliance, which must be worn by the patient as instructed by the orthodontist.

First surgical consultation

The initial surgical consultation includes a general discussion of the basic principles of combined orthodontic and surgical treatment and why surgery is necessary. The importance of a comprehensive treatment plan developed by both the orthodontist and surgeon is explained. At this consultation a systematic patient evaluation is conducted and records obtained (if duplicate records are not available).

Definitive surgical consultation

The definitive surgical consultation is conducted once the orthodontist and surgeon have finalized a treatment plan. The need for orthodontic preparation before surgery is confirmed. The basic principles of the specific surgical treatment, general sequence of events of the surgical phase of treatment, hospitalization time, time to recover, and the need for a soft food diet are discussed.

Treatment results of patients with similar dentofacial problems may be used to explain the surgical objectives. A patient information brochure is provided and the patient reassured that during the preoperative orthodontic phase, he or she is welcome to discuss with Dr. Baker any concerns regarding the planned surgery. The estimated costs, including costs of the planned surgery, hospitalization costs, and the anesthetization fee, should also be discussed at this stage.

Consultation with other disciplines

Consultation with practitioners in other disciplines may be needed in the treatment of patients with a dentofacial deformity.

Periodontic consultation

In general, most periodontal diseases should be treated prior to orthodontic banding. The teeth and periodontium should be sound before treatment. The importance of oral hygiene during the orthodontic treatment phase should be stressed and the possibility of periodontal treatment after debanding should be mentioned to the patient.

Prosthodontic consultation

Any work on fixed partial dentures preferably is performed after a period of orthodontic retention. However, it is often advantageous for the patient to consult with a prosthodontist before beginning treatment.

Implantology consultation

It is possible to place required osseointegrated implants at the time of orthognathic surgery. It is important, however, to keep any post-operative orthodontic tooth movement in mind. Dental implants can often be placed more accurately after band removal and a short period of retention.

General practitioner consultation

Problems such as dental caries, fractures, and crowns with poor fit should be treated before treatment commences. The condition of certain teeth may influence the choice of tooth extraction for orthodontic reasons. The initial referral to the orthodontist or surgeon is often made by the general practitioner, and it is important to keep him or her abreast of the treatment plan and progress of the patient's treatment.

Importance of communication

Adequate communication between the orthodontist, patient, and surgeon about the patient's main complaint and concerns, dentofacial diagnosis, treatment possibilities, and treatment objectives is crucial.  The treatment plan may need to be revised or changed after commencement of the preoperative orthodontic treatment. The reason for a change in treatment plan and the solution should be discussed by the orthognathic team. This will prevent any surprises at the immediate preoperative surgical consultation.

Superb orthodontic alignment of teeth and excellent surgical technique do not substitute for good clinical judgment, optimal decision making, proper communication, and empathy with patients.