Mandibular (Lower Jaw) Osteotomy

What does the operation involve?

The operation is undertaken through an incision made at the back of the mouth in the gum of the molar teeth to gain access to the jaw. The lower jaw is then cut in an oblique fashion with a small saw to allow it to be broken in a controlled manner. It is then moved into its new position, which has been predetermined during surgical planning with the aid of models of your teeth. A small plastic wafer is attached to the teeth to allow the new position of the lower jaw to be determined, which is then fixed into place with small metal plates and screws. These are made of titanium which is a very inert metal and safe to be used in the body. The gum is stitched back into place with dissolvable stitches.

What can I expect after the operation?

When you wake up from the operation you will have small elastic bands between your upper and lower jaw to help guide your jaws into there new positions. This means you will not be able to open your mouth fully.
This is not a very painful operation and when you initially wake up you will feel the area around the jaws to be numb. However you will find your mouth and jaws feel generally uncomfortable in the first 2-3 weeks following surgery. Regular simple painkillers are usually needed initially and these will be given to you to take home from hospital.
Swelling usually increases up to 4 days following surgery and will gradually settle. This can be reduced by using cold compresses.
Most of the swelling has usually disappears after a fortnight but there is often some subtle swelling that can take several months to disappear although only you and your family are likely to notice this.
It is also necessary to make sure that the area heals without any infection and so you will be given antibiotics through a vein in your arm whilst you are in hospital. When you go home antibiotics will also be given along with an antibacterial mouthwash.
It is likely that you will have a small amount of bleeding from the mouth for a few days following surgery. A sore throat and difficulty swallowing can also be expected.

What About Eating?

Initially you will be on a very soft diet and you will need a food processor at home to help with food preparation. After the first week or so you will be able to take soft foods. Normal eating usually returns over a 6-8 week period.

How long will I be in hospital?

Usually patients go home the following day after surgery, however sometimes two nights maybe indicated depending on home circumstances. You will be seen again in clinic one week following your surgery.

What About returning to work and sports?

This varies from person to person and also depends on what kind of job you do. We recommend that most people have about two-three weeks off work. It takes 6-8 weeks for bones to heal fully therefore we advise that you don’t undertake heavy manual work or contact sports during this healing phase. It is important to remember that you will not be able to drive or operate machinery for 48 hours after your general anaesthetic.

What are the possible problems?

There are potential complications with any operation. Fortunately with this type of surgery complications are rare and may not happen to you. However it is important that you are aware of them and have the opportunity to discuss them with your surgeon.
Bleeding – during surgery the risk of significant bleeding is low, but there is a risk of approximatley 1% of needing a blood transfusion. This would only be given if absolutely necessary. If there was significant bleeding during surgery there is a small chance that a small incision may need to be made in a crease in the neck in order to gain access to blood vessels to stop the bleeding. Following surgery some oozing from the cuts inside your mouth on the night of operation is normal and to be expected. Often you will notice slight bleeding from your nose as well which may take a week or so to settle. Again this is normal and nothing to be concerned about.

What about numbness ?

Your bottom lip will be numb and tingly after the operation, similar to the sensation after having an injection at the dentist. This numbness may take several months to disappear and in a minority of patients there may be some permanent changes in sesation of the lower lip.

What about infection ?

The small plates and screws that hold your jaw in its new position are usually left in place permanently. Occasionally they can become infected and need to be removed but if this happens it is not normally a problem until several months after surgery.

Is there a need for adjustment of the bite ?

In the weeks following surgery it is often necessary to put elastic bands on your orthodontic braces to guide your bite into its new position. Rarely a second small operation may be required to reposition the fixing plates and screws if your new bite is not quite right.

Is there a possibility of a non-union ?

Occasionally bones don’t heal as they should and if this does happen sometimes a second procedure is indicated. Problems like this are more likely to occur in smokers or in those who are immunosuppressed Eg diabetics.

What about follow-up?

A review appointment will be arranged before you leave hospital to see both the surgeon and orthodontist usually a week following surgery. You will need to come back regularly during the initial healing phase to ensure that your bite is maintained in its new position and for adjustment of the elastic bands between your teeth.

Chin Surgery (Genioplasty)

People seek advice for surgery of their chin and jaws for many reasons and at all ages. You may feel that your chin and jaw is either too small or too big and wish surgery to improve the appearance. Also if your chin or jaw is small then this may give unwanted prominence to the nose as well, and patient’s seeking nose surgery to reduce the size of the nose may not be aware that a small chin is just accentuating a slightly large nose. If this is the case then correction of the chin or jaw at the same time as nose surgery may help balance out your facial profile.
If you feel you have a problem with your chin or jaw then you need to be assessed regarding your chin, jaw and dental occlusion. Sometimes the actual jaws themselves maybe either too small or too large and the dental occlusion may need adjustment with braces and jaw surgery combined. This type of treatment is known as orthognathic surgery and involves input from both a Consultant Maxillofacial surgeon and a Consultant Orthodontist.
All patient’s considering chin and jaw surgery should be assessed with appropriate x-rays which look at the amount of bony movement required for the surgery and also to assess the jaw for any dental or bony pathology which may affect surgery.

Large Chin

If you have a large chin then surgery maybe undertaken in one of two ways to reduce the size.
A simple shaving of the chin may take away any undue pointedness of the chin and reduce the projection of the chin. This can be undertaken through a small incision in the mouth or alternatively an incision underneath the chin.
If your chin is quite large then a simple shaving may cause problems with excess soft tissue and sagging (ptosis) of the tissues overlying the bone. In this case a procedure to make a small bone cut across the chin and move it back may be necessary. The bone of the chin is usually fixed with some small plates and screws which remain in place following healing. This allows the soft tissue to remain attached to the bony chin surface and reduce the possible soft tissue ptosis following surgery.

Small Chin

If you have a small chin then there are a number of options which can be considered in order to give your jaw and face a better appearance. If your chin and jaw is of a normal height and width then a chin implant may be suitable to improve the projection of the chin. Generally implants are suitable for smaller advancements and if larger movements are needed to change the width or the height of the chin then a genioplasty should be considered.

Chin Implants

These have been made from a number of materials but the commonest ones in the market today are:
Silicone
Medpor (porous polyethylene)
PTFE (gortex)
All of these implant materials have been shown to be safe materials for this type of surgery. Implants maybe placed from an incision made either inside the mouth or from an incision made under the chin. The implant is placed adjacent to the chin point and fixed into position with either sutures or small screws and the wound is closed using resorbable sutures in the mouth or non-resorbable sutures under the chin.
Limitations of chin implants mean that they can only provide an augmentation of the chin without changing the vertical height or the width of the chin. They are usually placed for smaller chin augmentations. They risk getting infected and if this occurs the implant may need removing. This then needs to be either replaced once the infection has settled or a genioplasty undertaken. Sometimes the implant can cause wear on the underlying bone and occasionally causes damage to the underlying dental roots. They also can sometimes move around after placement unless securely fixed with screws. Sometimes the edges of the implant can be palpable.

Genioplasty

Genioplasty is a procedure that is often perceived as more invasive than the use of artificial chin implants as it means making a cut in the bone to move the chin. However, longer the bones heals into the new position and the new chin is just a normal part of the bony skeletal framework of the face. Problems such as implant movements, infection, bony erosion and implant rejection do not occur. The bony fragments are fixed together during the healing process with small titanium plates and screws which usually remain in place. These can occasionally need removal if they get infected but this is a minor procedure and does not affect the position or appearance of the chin.

Another advantage of the genioplasty over a chin implant is that if the bony chin is advanced, the muscles that support the floor of the mouth and the upper part of the neck are also advanced as they are attached to the posterior aspect of the chin. This will therefore improve the contour of the neckline at the same time.

The bony genioplasty also offers much greater versatility than an implant. As well as moving the chin forward or backward, you can also change the vertical height or the width of the chin by removing a small amount of the bone to reduce the height or the width, or by grafting to increase the height or the width of the chin. Grafting can be with either the patient’s own bone (preferred) or with a bone substitute which over a period of time (usually 12-18 months) will allow normal bone healing into the gap.

What is the Healing Process following surgery?

Chin surgery is usually carried out under general anesthesia although sometimes can be performed under local anesthetic with or without sedation if requested. Patients can resume their normal schedule in a span to 4 -5 days.
Some bruising and swelling will occur for the first few days and recovery to normal activity takes 7-14 days. The final shape of the new chin may not be fully appreciated until a number of months following surgery when all the swelling and tissue oedema has settled.
If an intra-oral approach is used then a soft diet is usually recommended for the first few days in order to allow the wound to heal. Antibiotics and mouthwash will usually be given and good oral hygiene is very important during this time.
Any sutures placed in the skin should be removed 6-7 days following surgery.

What are the possible complications of chin surgery?

Complications of any surgery include the risk of bleeding, infection or damage to adjacent structures. In the case of chin surgery there are nerves that supply sensation (feeling) to the lower lip. These can be stretched and bruised causing the lip to feel numb or tingly. This is usually temporary although it can take weeks to months to recover and in a small number of cases can persist permanently. The skin overlying the chin point can also feel numb following chin surgery, again this will usually recover with time.
The teeth can also be damaged in this type of surgery and this is why x-rays are undertake to assess the position and length of the teeth as well as to assess for any pre-exisitng dental or jaw problems.
Repeated chin surgery can weaken the muscle that helps support the chin tissues during talking and eating. If you require repeat chin surgery then occasionally we may recommend additional fixation of the soft tissues to try and prevent against problems with the soft tissues long term.
In summary there are a number of different types of chin surgery that can be undertaken and a full assessment both clinically and with radiographs is important to determine the best type of treatment.

Shape and size of the facial skeleton are fundamental determinants of facial appearance. Difference in facial skeletal support is one of the most important factors distinguishing people of different ethnic background. Facial contouring is a highly effective method of enhancing facial features and reducing the appearance of the signs of aging. Procedures range from facial implants, fat grafting to facial liposuction and lip contouring, chin and cheek augmentation to ear lobe surgery with neck and brow lift. Facial bone contouring surgery is an effective procedure for patients with wide or prominent zygoma and mandibular angle.

Integrated Team Approach

In addition to performing soft tissue and skeletal procedures, the cleft surgeon plays a primary role in coordinating the care from infancy through adolescence and beyond. The orthodontist provides interceptive treatment in childhood, identifies abnormal growth patterns of the facial skeleton, and carries out final orthodontic treatment in conjunction With orthognathic surgery.
The surgical techniques used for the correction of cleft deformities include Leforte I osteotomy, Sagittal split osteotomy (When indicated). Similar results can be obtained by Distraction Osteogenesis as well.

 What is Orthognathic Surgery?

“Surgery to create straight jaws” is the literal meaning of orthognathic surgery. It is usually undertaken to improve both the function and appearance of the upper and lower jaws, the teeth and the facial appearance as a whole. It is undertaken by a team consisting of a Consultant Orthodontist, along with a Consultant in Oral and Maxillofacial Surgery. Sometimes other professionals need to be involved such as Psychiatrists, Dieticians and Speech and Language therapists.

Orthognathic treatment has been shown to improve oral function, improve both dental and facial appearance and improve health related quality of life. In some cases the results of jaw surgery can be enhanced with the addition of other procedures such as nose surgery (rhinoplasty), chin surgery (genioplasty), or the placement of facial implants.

What causes jaw problems?

Large, small or asymmetric jaws may develop without a specific cause but often there is a genetic predisposition to uneven jaw size. Other causes include disturbance or jaw growth during development such as after a fracture of the jaw bone in childhood. Some children with specific conditions such as cleft lip and palate, or a syndrome known as hemifacial microsomia are more likely to require this type of treatment. Usually jaw discrepancies are noted as children grow and become more marked at puberty. Usually treatment is undertaken towards the end of growth during teenage years, although in some cases maybe started earlier.

Is there an upper age limit for treatment?

Adults can also undergo this type of treatment. This maybe indicated for a number of reasons:
They may have been unaware the treatment was available when they were younger and have functional problems with eating or with their occlusion (bite) teeth, or even wish to improve their appearance.
They may need this treatment due to facial surgery for trauma or other head and neck pathology causing disturbances in the bite (occlusion).
Sometimes we see patient’s who have had previous camouflage surgery eg a chin implant, or orthodontics to hide a small jaw and who would also benefit from orthognathic surgery.

What problems are caused by abnormal jaw relationships?

Mild jaw deformities and disturbances in the bite are relatively common and usually cause problems with the alignment of the teeth. This can sometimes be treated with the use of braces alone. In the UK this type or treatment is usually carried out by an orthodontist in high street practice. More severe facial deformities and jaw discrepancies cause a number of concerns and these patient’s are usually treated in a hospital setting with a Consultant Orthodontist and Consultant in Oral and Maxillofacial Surgery working together.
If dental and facial appearance is compromised this can lead to problems with increased stress and difficulty in forming interpersonal relationships, especially during the important formative teenage years. This ultimately reduces quality of life of the patient.
Jaw function can be compromised and this can result in problems with eating, damage to the gums and palate due to a traumatic bite, jaw muscle and jaw joint problems and speech difficulties.

What does Orthognathic Treatment involve?

Patient’s or their parents usually seek advice initially from there dentist or General Practioner. Older patient’s may seek advice for camouflage treatment directly from cosmetic surgeons and these patient’s should really be assessed fully by a Consultant Maxillofacial Surgeon and Consultant Orthodontist prior to proceeding to camouflage surgery so that they can be fully informed of all treatment options and complications before proceeding to surgery.
It is recognised that the gold standard for orthognathic treatment is provided in the hospital setting using the team approach. The clinicians working in this setting have all undergone the appropriate training and have extensive experience in this type of treatment. This multidisciplinery team approach allows close communication between all involved in a patient’s care.
Once a problem has been identified a referral can be made and the patient assessed fully by both a Maxillofacial Surgeon and an Orthodontist. This initial assessment will involve a full history and examination. Usually radiographic examination of the face and jaws with either x-rays or CT scans, impressions of the teeth and clinical photographs are undertaken for records and for undertaking cephalometrics (skull radiographic measurements). Using this information computer software programming can simulate proposed tooth and jaw movements to give a guide as to the post treatment outcome.
Once a patient has nearly finished growing (usually at 15-18 years of age) treatment planning can be discussed with patient’s and parents. If the patient then wishes, the initial phase of the treatment can start. Prior to any brace treatment all dental work should be completed and oral hygiene should be good. If this is not the case treatment will be delayed until good oral health has been achieved. This is because braces increase the risk of dental decay and can be detrimental if good oral hygiene measures are not undertaken.

Treatment Stages

Pre-surgical Orthodontic

Pre-surgical orthodontic treatment with braces and any necessary dental extractions will be carried out. This work is usually undertaken by a Hospital Consultant Orthodontist. Braces are attached to the teeth which are then adjusted on regular basis. This allows the teeth to straighten in each jaw so that the two jaws can fit together properly. At the start of this treatment it maybe necessary to have some teeth removed to make room for the teeth to be moved in the jaws. The most common teeth to be extracted are the premolar teeth although this may vary. Sometimes heavily filled teeth maybe extracted rather than healthy teeth if it is thought their long term prognosis is not as goood as the other teeth. Also at this time if you have wisdom teeth present in the lower jaw, they should also be removed. This is because lower jaw surgery is undertaken in the part of the jaw in which the wisdom teeth lie. If they are left in place the jaw surgery can be less predictable and so are usually removed at the start of treatment in order for bony healing at the extraction site to take place. This initial orthodontic stage usually lasts 12-18 months.

Surgery

Once tooth alignment has been achieved a final surgical plan is made between the maxillofacial surgeon and the orthodontist. Impressions of the teeth are undertaken and using specially trained maxillofacial technicians the planned surgery in simulated on the models of the teeth. This allows acrylic splints to be made which allow the surgeon to correctly position the teeth at the time of surgery. Both immediately prior to and following the surgery the frequency of the visits to both surgeon and orthodontist will increase to ensure the preparation for surgery is correct and the immediate post operative position of the teeth and jaws is optimised and maintained.

Post Surgical Orthodontics

Following surgery there may be some fine adjustments that need to be made to the position of the teeth, therefore the braces usually stay in position until 4-6 months after. Following removal of the braces you will need to wear retainers on your teeth for a year initially and then at night only for many years as teeth will always have a tendancy to try and return to the position they came from!

Is it worth it?

Initially you may think this is not for you as both the treatment time and surgery requires significant time off work, discomfort etc. However the end result is that your facial skeleton is healed in its new position and this will remain with you for the rest of your life. Patient satisfaction for this type of treatment is very high despite the long course of treatment involved. There are many patient’s who have undergone this type of treatment and would be more than happy to discuss there experiences.

ORAL & MAXILLOFACIAL SURGEONS

Dr. S.M.Kotrashetti	Dr. Tejraj P Kale	Dr. Abhishek Motimath

ORTHODONTIST

Dr. K.M. Keluskar	Dr. Amit Nilgar

ADVISORY BOARD

Dr.Gosla Reddy DIRECTOR, GSR HOSPITAL FOR CLEFT AND CRANIOFACIAL SURGERY, HYDERABA