||It has been suggested that Dentofacial osteotomy be merged into this article. (Discuss) Proposed since December 2016.|
Relationship between mandible and maxilla
Orthognathic surgery (// OR-thəg-NATH-ik) is surgery to correct conditions of the jaw and face related to structure, growth, sleep apnea, TMJ disorders, malocclusion problems owing to skeletal disharmonies, or other orthodontic problems that cannot be easily treated with braces. Originally coined by Harold Hargis, it is also used in treatment of congenital conditions like cleft palate. Bones can be cut and re-aligned, then held in place with either screws or plates. Orthognathic surgery can also be referred to as corrective jaw surgery.
It is estimated that nearly 5% of the UK or USA population present with dentofacial deformities that are not amenable to orthodontic treatment requiring orthognathic surgery as a part of their definitive treatment. Orthognathic surgery can be used to correct;
- Gross jaw discrepancies (anteroposterior, vertical, or transverse discrepancies)
- Facial skeletal discrepancies associated with documented sleep apnea, airway defects, and soft tissue discrepancies
- Facial skeletal discrepancies associated with documented temporomandibular joint pathology
Cleft lip and palate
Orthognathic surgery is a well established and widely used treatment option for insufficient growth of the maxilla in patients with an orofacial cleft. There is some debate regarding the timing of orthognathic procedures, to maximise the potential for natural growth of the facial skeleton. Patient reported aesthetic outcomes of orthognathic surgery for cleft lip and palate appear to be of overall satisfaction, despite complications that may arise. A potentially significant long-term outcome of orthognathic surgery is impaired maxillary growth, due to scar tissue formation. The Cochrane collaboration released a systematic review comparing traditional orthognathic surgery with maxillary distraction osteogenesis. The review found both procedures effective, but suggested distraction osteogenesis may reduce the incidence of long-term relapse. It should be noted that the quality of evidence was rated low, as only one study was included.
Like any other surgery, there can be complications such as bleeding, swelling, infection, nausea and vomiting. There could also be some numbness in the face due to nerve damage. The numbness may be either temporary, or, more rarely, permanent. In general, complications of this surgery occur infrequently. The surgery required has led, in some cases, to identity crisis in patients, whereby the new facial structure has a negative impact mentally of how the patient perceives themselves.
Orthognathic surgery is performed by an oral and maxillofacial surgeon in collaboration with an orthodontist. It often includes braces before and after surgery, and retainers after the final removal of braces. Orthognathic surgery is often needed after reconstruction of cleft palate or other major craniofacial anomalies. Careful coordination between the surgeon and orthodontist is essential to ensure that the teeth will fit correctly after the surgery.
Planning for the surgery usually involves input from a multidisciplinary team. Involved professionals are oral and maxillofacial surgeons, orthodontists, and occasionally a speech and language therapist. Although it depends on the reason for surgery, working with a speech and language therapist in advance can help minimize potential relapse. As the surgery usually results in a noticeable change in the patient's face a psychological assessment is occasionally required to assess patient's need for surgery and its predicted effect on the patient.
Radiographs and photographs are taken to help in the planning and there is software to predict the shape of the patient's face after surgery, which is useful both for planning and for explaining the surgery to the patient and the patient's family. Advanced software can allow the patient to see the predicted results of the surgery.
The main goals of orthognathic surgery are to achieve a correct bite, an aesthetic face and an enlarged airway. While correcting the bite is important, if the face is not considered the resulting bone changes might lead to an unaesthetic result. Orthognathic surgery is also available as a very successful treatment (90–100%) for obstructive sleep apnea. Great care needs to be taken during the planning phase to maximize airway patency.
The surgery might involve one jaw or the two jaws during the same procedure. The modification is done by making cuts in the bones of the mandible and / or maxilla and repositioning the cut pieces in the desired alignment. Usually surgery is performed under general anaesthetic and using nasal tube for intubation rather than the more commonly used oral tube; this is to allow wiring the teeth together during surgery. The surgery often does not involve cutting the skin, and instead, the surgeon is often able to go through the inside of the mouth.
Cutting the bone is called osteotomy and in case of performing the surgery on the two jaws at the same time it is called a bi-maxillary osteotomy (two jaws bone cutting) or a maxillomandibular advancement. The bone cutting is traditionally done using special electrical saws and burs, and manual chisels. The recent advent of piezoelectric saws have simplified bone cutting, but such equipment has not yet become the norm outside of the most developed countries. The maxilla can be adjusted using a "Lefort I" level osteotomy (most common). Sometimes the midface can be mobilised as well by using a Lefort II, or Lefort III osteotomy. These techniques are utilized extensively for children suffering from certain craniofacial abnormalities such as Crouzon syndrome.
The jaws will be wired together (inter-maxillary fixation) using stainless steel wires during the surgery to ensure the correct re-positioning of the bones. This in most cases is released before the patient wakes up. Some surgeons prefer to wire the jaws shut.
In some cases, the changing of the jaw structure will cause the cheeks to become depressed and shallow. Some procedures will call for the insertion of implants to give the patient's face a fuller look.
After orthognathic surgery, patients are often required to adhere to an all-liquid diet. After time, soft food can be introduced, and then hard food. Diet is very important after the surgery, to accelerate the healing process. Weight loss due to lack of appetite and the liquid diet is common, but should be avoided if possible. Normal recovery time can range from a few weeks for minor surgery, to up to a year for more complicated surgery.
For some surgeries, pain may be minimal due to minor nerve damage and lack of feeling. Doctors will prescribe pain medication and prophylactic antibiotics to the patient. There is often a large amount of swelling around the jaw area, and in some cases bruising. Most of the swelling will disappear in the first few weeks, but some may remain for a few months.
The surgeon will see the patient for check-ups frequently, to check on the healing, check for infection, and to make sure nothing has moved. The frequency of visits will decrease over time. If the surgeon is unsatisfied with the way the bone is mending, she/he may recommend additional surgery to rectify whatever may have shifted. It is very important to avoid any chewing until the surgeon is satisfied with the healing.
- Bill J, Proff P, Bayerlein T, Blens T, Gedrange T, Reuther J (September 2006). "Orthognathic surgery in cleft patients". J Craniomaxillofac Surg. 34 (Suppl 2): 77–81. doi:10.1016/S1010-5182(06)60017-6. PMID 17071397.
- Posnick, Jeffrey C. (September 2013). Orthognatic Surgery: Principles and Practice. Amsterdam: Elsevier. pp. 61–68. doi:10.1016/B978-1-4557-2698-1.00003-4. ISBN 978-145572698-1.
- Harrington C, Gallagher JR, Borzabadi-Farahani A (2015). "A retrospective analysis of dentofacial deformities and orthognathic surgeries using the index of orthognathic functional treatment needs (IOFTN).". Int J Pediatr Otorhinolaryngol. 79 (7): 1063–6. doi:10.1016/j.ijporl.2015.04.027. PMID 25957779.
- Borzabadi-Farahani A, Eslamipour F, Shahmoradi M (2016). "Functional needs of subjects with dentofacial deformities: A study using the index of orthognathic functional treatment need (IOFTN)". J Plast Reconstr Aesthet Surg. 69 (6): 796–801. doi:10.1016/j.bjps.2016.03.008. PMID 27068664.
- "Ortho Criteria". AAOMS.org. American Association of Oral and Maxillofacial Surgeons. Retrieved 2014-11-05.
- DeLuke, Dean M; Marchand, Anick; Robles, Elizabeth C; Fox, Patricia. "Facial growth and the need for orthognathic surgery after cleft palate repair: Literature review and report of 28 cases". Journal of Oral and Maxillofacial Surgery. 55 (7): 694–697. doi:10.1016/s0278-2391(97)90579-6.
- Wolford, Larry M.; Stevao, Eber L.L. (2016-11-10). "Correction of jaw deformities in patients with cleft lip and palate". Proceedings (Baylor University. Medical Center). 15 (3): 250–254. ISSN 0899-8280. PMC . PMID 16333445.
- Munz, S. M.; Edwards, S. P.; Inglehart, M. R. (2011-08-01). "Oral health-related quality of life, and satisfaction with treatment and treatment outcomes of adolescents/young adults with cleft lip/palate: an exploration". International Journal of Oral and Maxillofacial Surgery. 40 (8): 790–796. doi:10.1016/j.ijom.2011.03.002.
- Gkantidis, Nikolaos; Papamanou, Despina A.; Christou, Panagiotis; Topouzelis, Nikolaos. "Aesthetic outcome of cleft lip and palate treatment. Perceptions of patients, families, and health professionals compared to the general public". Journal of Cranio-Maxillofacial Surgery. 41 (7): e105–e110. doi:10.1016/j.jcms.2012.11.034.
- Daskalogiannakis, John; Mehta, Manisha (2009-10-05). "The Need for Orthognathic Surgery in Patients With Repaired Complete Unilateral and Complete Bilateral Cleft Lip and Palate". The Cleft Palate-Craniofacial Journal. 46 (5): 498–502. doi:10.1597/08-176.1.
- "Maxillary distraction osteogenesis versus orthognathic surgery for cleft lip and palate patients - Kloukos - 2013 - The Cochrane Library - Wiley Online Library". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd010403.
- Silva AC, O'Ryan F, Poor DB (September 2006). "Postoperative nausea and vomiting (PONV) after orthognathic surgery: a retrospective study and literature review". J. Oral Maxillofac. Surg. 64 (9): 1385–97. doi:10.1016/j.joms.2006.05.024. PMID 16916674.
- Eckert AW, Maurer P, Kriwalsky MS, Schubert J (September 2006). "P.292 Complications in orthognathic surgery". J Craniomaxillofac Surg. 34 (Suppl 1): 206. doi:10.1016/S1010-5182(06)60797-X.
- Panula K, Finne K, Oikarinen K (October 2001). "Incidence of complications and problems related to orthognathic surgery: a review of 655 patients". J. Oral Maxillofac. Surg. 59 (10): 1128–36; discussion 1137. doi:10.1053/joms.2001.26704. PMID 11573165.
- Mischkowski RA, Zinser MJ, Kübler AC, Krug B, Seifert U, Zöller JE (December 2006). "Application of an augmented reality tool for maxillary positioning in orthognathic surgery — a feasibility study". J Craniomaxillofac Surg. 34 (8): 478–83. doi:10.1016/j.jcms.2006.07.862. PMID 17157519.
- Uechi J, Okayama M, Shibata T, et al. (December 2006). "A novel method for the 3-dimensional simulation of orthognathic surgery by using a multimodal image-fusion technique". Am J Orthod Dentofacial Orthop. 130 (6): 786–98. doi:10.1016/j.ajodo.2006.03.025. PMID 17169742.
- Tsuji M, Noguchi N, Shigematsu M, et al. (September 2006). "A new navigation system based on cephalograms and dental casts for oral and maxillofacial surgery". Int J Oral Maxillofac Surg. 35 (9): 828–36. doi:10.1016/j.ijom.2006.02.024. PMID 16690251.
- Arnett GW, Gunson MJ (September 2004). "Facial planning for orthodontists and oral surgeons". Am J Orthod Dentofacial Orthop. 126 (3): 290–5. doi:10.1016/S0889540604005232. PMID 15356488.
- Prinsell JR (December 1999). "Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients". Chest. 116 (6): 1519–29. doi:10.1378/chest.116.6.1519. PMID 10593771.