Jaw Surgery Washington DC/McLean/Tyson’s Corner

Introduction

When a patient has a malocclusion that the orthodontist cannot correct with orthodontics alone, he/she may request that the patient see a surgeon to move the jaws into a more favorable position to eliminate the discrepancy between the upper and lower jaws. Orthognathic surgery (jaw surgery) is the name of the surgery that moves the jaws into a position so that the orthodontist can align the teeth into their optimal position. Patients may be referred to Dr. Baker when starting orthodontic therapy (it is obvious jaw surgery may be indicated), during orthodontic therapy (the orthodontist underestimated the difficulty of the patient’s malocclusion), or after braces are complete (the patient knew they would need surgery and decided to just see the surgeon when they were ready). Dr. Baker will review the advantages and disadvantages of both a surgical and nonsurgical approach so that each patient can make the best decision for them at the time.

Dr. Baker’s Credentials for Jaw Surgery

  • Professor of Plastic Surgery, Medstar Georgetown Department of Plastic Surgery
  • Director, Medstar Georgetown Center for Facial Restoration
  • Dr. Baker was one of the first surgeons in the world to use Virtual Surgical Planning (VSP) in jaw surgery and continues to develop curricula and teach at symposia on this topic.
  • Training in dental, medical, oral and maxillofacial, plastic surgery, and craniofacial training. He is one of a select few surgeons in the world with this type of experience in the treatment of malocclusions with jaw surgery.
  • Plastic surgery knowledge of facial aesthetics gives him insight in planning BOTH a functional and aesthetic result.
  • International and national lecturer on jaw surgery
  • Published many articles on jaw surgery
  • Published many chapters on jaw surgery
  • Edited textbooks on jaw surgery
  • Leader in quality of life and outcomes studies in jaw surgery
  • Pioneer of virtual surgical planning (computer aided surgical simulation)
  • American Society of Maxillofacial Surgeons Visiting Professor on jaw surgery
  • IN NETWORK WITH MOST INSURANCE PLANS

The Best Candidates for Jaw Surgery

The combination of surgery and orthodontic treatment makes it possible to treat jaw abnormalities that cannot be corrected solely with orthodontic therapy. When a patient presents with a discrepancy in their jaw alignment, three options are possible to correct their occlusion:

  1. Growth modification. In growing children, dentofacial orthopedics (headgear, etc.) can nonsurgically modify jaw position to some extent if done early.
  2. Orthodontic compensation. The jaws are misaligned but to avoid surgically moving the jaws, the orthodontist will move the upper and lower teeth together without properly aligning the jaw relationship. This approach may require extraction of normal adult teeth to create a normal occlusion. The problem with this approach is that the teeth will look good, but the aesthetics of the face frequently are compromised. The most common example of this is the orthodontic correction of the overbite (the most common malocclusion in the United States). An overbite is caused by a small mandible (lower jaw). Ideally, the lower jaw would be advanced to restore the proper relationship to the upper jaw. If compensation is used to correct the occlusion, the upper teeth are pulled backward to meet the lower teeth. Unfortunately, the upper lip falls backward too because there is a loss of upper lip support. Now the nose looks big because the upper lip is back, the lower jaw is back, and the chin is back. This appearance of a weak chin and a large nose is almost always the result of a compensated overbite that was solved solely with orthodontics when surgery likely would have provided a superior functional and aesthetic result. Many of Dr. Baker’s cosmetic patients have had compensatory orthodontics and later present to correct the adverse aesthetic consequences with rhinoplasty, chin surgery, or a necklift.
  3. Orthognathic surgery. Combined orthodontic and surgical correction is considered the best treatment modality for dentofacial imbalances once growth has ceased. By properly restoring the relationship of the upper and lower jaws, the desired occlusion can be achieved while also optimizing facial form and aesthetics.

Treatment Objectives in Orthognathic surgery

The goal of orthognathic surgery is to produce a normal class I occlusion while optimizing facial aesthetics. It is important to remember that jaw surgery is not primarily a cosmetic procedure, it is reconstructive. However, since Dr. Baker will be moving the jaws to produce the best occlusion, it is important to also implement the plastic surgery principles of facial aesthetics to achieve this normal occlusion while maintaining the best facial proportion.

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.

Aesthetics

Because of his experience as a plastic surgeon, Dr. Baker can treatment plan a functional operation that will achieve an excellent aesthetic result for the patient at the time of surgery but also one that will designed to maintain ideal facial aesthetics as the patient ages. Dr. Baker has the experience to incorporate this into each patient’s treatment plan because he not only performs jaw surgery on young patients, but treats adults for facial rejuvenation as well. His treatment plan is designed to place the jaws in a position that will avoid a prematurely aged look and enhance the longevity of youthful facial features as his patient ages. Dr. Baker has spent his career studying and researching the relationship between the soft tissue of the face and its relationship to the underlying facial skeleton.

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.

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. He will review specifics of the surgery with plastic models in his office. 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 to 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.

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 wiII 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.

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 Dr. Baker is explained. At this consultation a systematic patient evaluation is conducted and records obtained (if duplicate records are not available).

The definitive surgical consultation is conducted once the orthodontist and surgeon have finalized a treatment plan. 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.

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