The most common dentofacial disharmonies are large jaw, small jaw, long face, old face, facial asymmetry and open bite. The best way to solve these imbalances is by combining orthognathic surgery with orthodontics. This treatment will be based on different phases, which I explain below.
Initial Orthognathic Surgery Evaluation
The initial evaluation should be done jointly by the orthodontist and the surgeon.
The first visit should discuss the patient’s main concerns, the main reason for consultation or complaint, as well as the patient’s expectations of both orthodontic treatment and surgery.
A dental medical history specifically designed for this treatment will also be taken. It will therefore be necessary to order a series of complementary tests in order to make a good diagnosis. The complementary examinations consist of:
- Photographs of the face and bite.
- Special x-rays of the face with soft tissue contrast and at rest.
- Models or impressions of your teeth and occlusion.
In the second visit, the so-called treatment plan is established. Before this visit, all complementary examinations should be ready.
The patient is presented with the different treatment options, as well as their benefits and possible disadvantages. Therefore, it is necessary for the orthognathic surgeon to be both a physician and a dentist, as only in this way will he/she be able to correctly treat and understand this anomaly, offering the different treatment options from an esthetic, functional and dental point of view.
Phases of Orthognathic Surgery
The surgical treatment of orthognathic surgery consists of three phases:
1. Pre-surgical orthodontics:
The orthodontist will try to align the teeth, correct inclinations, defeat the teeth, coordinate the arches separately… trying to place the teeth in the best possible position. In this period, the occlusion could worsen, although without major concerns since it is a perfectly planned treatment, and once the bones have moved, the teeth will fit well. One week before the surgery, the following procedures will be performed:
- A few days before surgery, the orthodontic archwire will be changed for a larger caliber one, being able to place metal bands on the last molar, soldered clasps or make an archwire with small loops, in order to help the stability of the operation.
- New dental models, together with radiographs and photos.
- If Bimaxillary surgery is to be performed, a blood donation may be ordered and saved for possible autotransfusion.
- A complete medical history, physical examination and complete preoperative workup will be performed.
2. Orthognathic surgery
This surgery should be performed in a hospital center, in an operating room and under general anesthesia. Surgical times will depend on the surgeon’s experience and the complexity of the intervention, varying between two and five hours.
It is the surgeon’s job to take the following pre-surgical, intra-surgical and post-surgical measures:
- Controlled and continuous arterial hypotension during the entire operation.
- Dental fixation with wire in oral intubations or cephalic fixation technique with adhesive in case of nasal intubation.
- Compression stockings and adequate angulation of the surgical table.
- Anti-edema therapy, 24 hours before surgery.
- Model surgery performed by the surgeon
- Surgical guide, intermediate and final splints
- Simplified segmental osteotomies
- State-of-the-art fixation material
- Special instruments
- Equipment for facial osteotomies
3. Post-surgical orthodontics
Once the postoperative period is over and the surgical recovery period is finished, the surgeon will send the patient back to the orthodontist to continue and finish the treatment.
Postoperative period after orthognathic surgery
The recovery time after surgery depends on different factors, but normally patients return to their daily activities ten to fifteen days after the operation.
However, they will have to go through a series of limitations beforehand:
- Dietary restrictions
- The first days after the operation, the diet will consist of soups, creams, juices or any food that can be liquefied. Between seven and fifteen days, the diet may be soft.
- Limitation in the opening of the mouth.
- Most of the patients leave the operating room without having their mouth opening limited, although once the intervention has been performed it is necessary to use intermaxillary elastics whose purpose is to guide the occlusion. This therapy offers some limitation of movement and will continue for six weeks.
The osteotomies or bone cuts normally used in orthognathic surgery can be used for other techniques:
- Assisted bone expansion: in the case of teeth that are crowded or mounted one on top of the other, usually due to a dental bone imbalance of space, tooth extractions should be performed first, with the consequences of extracting a healthy tooth. The orthognathic surgeon can be called in to evaluate the possibility of space augmentation to avoid extraction.
- Segmental osteotomies: they are used to make cuts between the teeth and mobilize them to a better position. Among the most commonly used techniques are the following:
– Restoring the line of occlusion
– Change of inclination of anterior or lower teeth
– Surgical closure of edentulous spaces
– Correction of severe malocclusions