Category Archives: Orthognathic Surgery

Orthognathic (Jaw) Surgery | Corrective Jaw Surgery | Oral …

Corrective jaw surgery, or orthognathic surgery, is performed by Oral and Maxillofacial Surgeons to correct a wide range of minor and major skeletal and dental irregularities, including the misalignment of jaws and teeth, which, in turn, can improve chewing, speaking and breathing. While the patients appearance may be dramatically enhanced as a result of their surgery, orthognathic surgery is performed to correct functional problems.

Following are some of the conditions that may indicate the need for corrective jaw surgery:

People who may benefit from corrective jaw surgery include those with an improper bite resulting from misaligned teeth and/or jaws. In some cases, the upper and lower jaws may grow at different rates. Injuries and birth defects may also affect jaw alignment. While orthodontics can usually correct bite, or occlusion, problems when only the teeth are misaligned, corrective jaw surgery may be necessary to correct misalignment of the jaws.

Your dentist, orthodontist and Oral and Maxillofacial Surgeon will work together to determine whether you are a candidate for corrective jaw, or orthognathic, surgery. The Oral and Maxillofacial Surgeon determines which corrective jaw surgical procedure is appropriate and performs the actual surgery. It is important to understand that your treatment, which will probably include orthodontics before and after surgery, may take several years to complete. Your Oral and Maxillofacial Surgeon and orthodontist understand that this is a long-term commitment for you and your family.They will try to realistically estimate the time required for your treatment.

Corrective jaw surgery may reposition all or part of the upper jaw, lower jaw and chin. When you are fully informed about your case and your treatment options, you and your dental team will determine the course of treatment that is best for you.

Correcting an Open Bite: Some of the bone in the upper tooth-bearing portion of the jaw is removed. The upper jaw is then secured in position with plates and screws.

Correcting a Protruding Lower Jaw:The bone in the rear portion of the jaw is separated from the front portion and modified so that the tooth-bearing portion of the lower jaw can be moved back for proper alignment.

Correcting a Receding Lower Jaw or Weak Chin:The bone in the lower portion of the jaw is separated from its base and modified. The tooth-bearing portion of the lower jaw and a portion of the chin are repositioned forward.

Before your surgery, orthodontic braces move the teeth into a new position. Because your teeth are being moved into a position that will fit together after surgery, you may at first think your bite is getting worse rather than better. When your Oral and Maxillofacial Surgeon repositions your jaws during surgery, however, your teeth should fit together properly.

As your pre-surgical orthodontic treatment nears completion, additional or updated records, including x-rays, pictures and models of your teeth, may be taken to help guide your surgery.

Depending on the procedure, corrective jaw surgery may be performed under general anesthesia in a hospital, an ambulatory surgical center or in the oral and maxillofacial surgery office. Surgery may take from one to several hours to complete.

Your Oral and Maxillofacial Surgeon will reposition the jawbones in accordance with your specific needs. In some cases, bone may be added, taken away or reshaped. Surgical plates, screws, wires and rubber bands may be used to hold your jaws in their new positions. Incisions are usually made inside the mouth to reduce visible scarring; however, some cases do require small incisions outside of the mouth. When this is necessary, care is taken to minimize their appearance.

After surgery, your surgeon will provide instructions for a modified diet, which may include solids and liquids, as well as a schedule for transitioning to a normal diet. You may also be asked to refrain from using tobacco products and avoid strenuous physical activity.

Pain following corrective jaw surgery is easily controlled with medication and patients are generally able to return to work or school from one to three weeks after surgery, depending on how they are feeling. While the initial healing phase is about six weeks, complete healing of the jaws takes between nine and 12 months.

Corrective jaw surgery moves your teeth and jaws into positions that are more balanced, functional and healthy. Although the goal of this surgery is to improve your bite and function, some patients also experience enhancements to their appearance and speech. The results of corrective jaw surgery can have a dramatic and positive effect on many aspects of your life. So make the most of the new you!

The information provided here is not intended as a substitute for professional medical advice, diagnosis, or treatment. It is provided to help you communicate effectively with your oral and maxillofacial surgeon. Always seek the advice of your oral and maxillofacial surgeon regarding an oral health concern.

The American Association of Oral and Maxillofacial Surgeons (AAOMS), the professional organization representing more than 9,000 oral and maxillofacial surgeons in the United States, supports its members ability to practice their specialty through education, research and advocacy. AAOMS members comply with rigorous continuing education requirements and submit to periodic office examinations, ensuring the public that all office procedures and personnel meet stringent national standards.

2006-2012 American Association of Oral and Maxillofacial Surgeons (AAOMS). All rights reserved.

Reprinted with permission from American Association of Oral and Maxillofacial Surgeons.

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Orthognathic (Jaw) Surgery | Corrective Jaw Surgery | Oral …

Jaw Surgery Philadelphia | Orthognathic Surgery King of …

When Is Jaw Surgery Needed?

Orthognathic surgery is needed when jaws dont meet correctly and/or teeth dont seem to fit with jaws. Teeth are straightened with orthodontics and corrective jaw surgery repositions misaligned jaws. This not only improves facial appearance, but also ensures that teeth meet correctly and function properly.

People who can benefit from orthognathic surgery include those with an improper bite or jaws that are positioned incorrectly. Jaw growth is a gradual process and in some instances, the upper and lower jaws may grow at different rates. The result can be a host of problems that can affect chewing function, speech, long-term oral health and appearance.

Injury to the jaw and birth defects can also affect jaw alignment. Orthodontics alone can correct bite problems when only the teeth are involved. Orthognathic surgery may be required for the jaws when repositioning in necessary.

Difficulty in the following areas should be evaluated:

Any of these symptoms can exist at birth, be acquired after birth as a result of hereditary or environmental influences or as a result of trauma to the face. Before any treatment begins, a consultation will be held to perform a complete examination with x-rays. During the pre-treatment consultation process, feel free to ask any questions that you have regarding your treatment. When you are fully informed about the aspects of your care, you and your dental team will make the decision to proceed with treatment together.

Pre-operative photo of patient with severe mid-face, upper jaw and lower jaw deformity.

Post-operative photo 6 weeks after upper and lower jaw surgery, cheekbone implants, neck liposuction, nasal surgery and chin reduction.

The doctors at Pennsylvania Oral and Maxillofacial Surgery, LTD use modern computer techniques and three-dimensional models to show you exactly how your surgery will be approached. Using comprehensive facial X-rays and computer video imaging, we can show you how your bite will be improved and even give you an idea of how youll look after surgery. This helps you understand the surgical process and the extent of the treatment prescribed. Our goal is to help you understand the benefits of orthognathic surgery.

If you are a candidate for Corrective Jaw Surgery, our doctors will work closely with your dentist and orthodontist during your treatment. The actual surgery can move your teeth and jaws into a new position that results in a more attractive, functional and healthy dental-facial relationship.

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What Does Orthognathic Surgery Cost | Colgate Oral Care

Orthognathic surgery is a corrective jaw surgery that straightens or realigns your jaw, and corrects related skeletal deformities that a patient may need. At minimum, orthognathic surgery cost includes surgeon fees, hospital fees, orthodontics charges, anesthesia fees and pain medications. However, final expenses may depend on a number of conditions unique to the person.

About Orthognathic Surgery

This type of surgery, done by an oral and maxillofacial surgeon (OMS) in a hospital setting which involves straightening and realigning the jaws using surgical plates or templates, screws and wires.

Why would you invest in this treatment? The main purpose is to correct a severe malocclusion (improper bite) that may be causing functional problems in daily behavior, such as speech, chewing food or even sleep apnea. You might also experience headaches, joint pain or periodontal (gum) discomfort. According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), the following conditions may also prompt a need for orthognathic surgery:

How Orthodontics Can Affect Price

Although children may have certain birth conditions or orthodontic problems eventually requiring jaw surgery, it is generally appropriate only after he stops growing. That age is usually around 13 to 15 for girls and 16 to 18 for boys, according to Mayo Clinic. Nonetheless, early detection and treatment of a child’s orthodontic problems can often prevent the need for surgery altogether.

Usually, you wear braces for nine to 18 months before the surgery. After your jaw recovers from the surgery, your orthodontist finishes aligning your teeth and eventually removes the braces. The entire orthodontic process, including surgery, may take one to three years.

Risks During Treatment

The surgery usually takes one to three hours, and requires general anesthesia, which tends to carry the risks of any major treatment. These risks include pain, swelling, bleeding, infection and adverse reaction to anesthesia. More involved processes can theoretically damage nearby bone or gums, and the anesthetic itself may cause numbness in similar areas. You typically stay in the hospital for one to two days, and have a six-week at-home recovery time. Be sure to follow your doctor’s instructions for home-based oral care, which, for children, typically includes brushing after every meal using a small, gentle kids’ toothbrush such as the My First Colgate toothbrushes and toothbrushes for older children or tweens.

Cost and Insurance

Without health insurance, according to CostHelper, orthognathic surgery cost in the United States can range from about $20,000 to well over $40,000. Beyond orthodontics, other factors that can sway the cost include severity of the jaw misalignment and what type of surgery is required. Your location, the hospital treating you and complications during care can all make a difference as well.

In general, corrective jaw surgery is considered a medical procedure, not a cosmetic procedure, and is necessary to prevent more expensive medical and dental problems later in life. For this reason, some health insurance policies cover at least part of the cost of orthognathic surgery.

However you look to meet these requirements, explore any necessary pre-approvals and understand what your insurance will and will not pay for prior to treatment.

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What Does Orthognathic Surgery Cost | Colgate Oral Care

Wellington Village Orthodontics in Ottawa are Proud to be Founding Members of the Elite Lingual Orthodontists Study … – Digital Journal (press…

Ottawa, Ontario – Wellington Village Orthodontics, one of the leading orthodontists in Ottawa, is proud to announce its membership in the Elite Lingual Orthodontic Study Club, also known as ELOS. Dr. Andrea Picard, a certified specialist in Orthodontics, gained membership into this group as an elite lingual orthodontic specialist, offering invisible care to those in and around Ottowa.

Wellington Village Orthodontics offers regular braces, invisible braces and Invisalign to children, teenagers and adults. Dr. Picards goal is to assist patients in finding the best treatment to meet their expectations and needs. What she loves the most is to witness how a new smile can gradually transform a patient and help them gain confidence throughout treatment. According to Dr. Picard, We strive for perfection in my practice by offering personalized treatments adapted to each patient and by integrating innovation with tradition. We absolutely love our career choice and the lifelong relationships that we form with patients.

This Ottawa Orthodontists state-of-the-art clinic at Wellington Village Orthodontics offers a wide variety of orthodontic treatments, including lingual braces. The practice tailors the treatment to their patients needs. The techniques and appliances used include growth modification, combined treatment with orthognathic surgery and combined treatment with temporary anchorage devices, or TADs.

Dr. Picard, as a proud member of ELOS, offers both Invisalign and lingual braces options such as Suresmile, Harmony and Incognito braces. The Practices mission is to provide individuals and families with the highest quality care possible in a welcoming environment and with the most up-to-date techniques. Wellington Village Orthodontics offers Suresmile as a state of the art lingual braces option. All of Wellingtons surgical cases use this technology since the final occlusion is planned even before the surgery, leading to a shorter treatment post-surgery. With the Suresmile technology, which starts from an intra-oral (no radiation) scan taken of a patients teeth, this Orthodontist in Ottawa gets an incredible amount of information that would not be otherwise accessible, such as the variations of the anatomy of the teeth and their precise measurements. With this knowledge in hand, Dr. Picard can give patients an incredible level of custom orthodontic care.

Dr. Andrea Picards Wellington Village Orthodontics practice is located at 175 Holland Ave, Suite 300 Ottawa, ON K1Y 0Y2. Patients can contact or set an appointment with Dr. Picard at (613) 722-8500. Patients can also reach the office by email at info@bracesinottawa.com or visit their practice website at http://bracesinottawa.com/.

Media Contact Company Name: Wellington Village Orthodontics Contact Person: Dr. Andrea Picard Email: info@bracesinottawa.com Phone: 613-722-8500 Address:175 Holland Ave Suite 300 City: Ottawa State: Ontario Country: Canada Website: http://bracesinottawa.com/

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Wellington Village Orthodontics in Ottawa are Proud to be Founding Members of the Elite Lingual Orthodontists Study … – Digital Journal (press…

Treatment for Malocclusion-Topic Overview – WebMD

Orthognathic surgery treats malocclusion (“poor bite”) by restructuring the jaw through cutting the bone and repositioning the bone segments.

Adults who have jaw-related malocclusion are sometimes offered a choice between simple orthodontic treatment and orthodontic treatment combined with orthognathic surgery. Adults who have severe jaw problems may need surgery to improve their looks and how the jaw works. Severe jaw problems can include upper jaws that don’t match with the lower jaws.

Oral and maxillofacial surgeons or plastic surgeons perform this surgery using general anesthesia. Recovery takes several weeks. While the bone slowly heals, the jaw is held in place with wires or plates and screws.

The most common problem after this surgery is numbness of the upper or lower lip (paresthesia). Other risks include infection, bleeding (hemorrhage), swelling, muscle spasm, and temporomandibular disorder.

For most people, orthognathic surgery is elective, based on personal choice. Because orthognathic surgery requires a long and difficult recovery period, you should carefully weigh the benefits against the hardship and expense of the surgery.

For those few people who also have serious functional problems, such as problems with chewing or closing the mouth, orthognathic surgery may be a necessity.

WebMD Medical Reference from Healthwise

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Treatment for Malocclusion-Topic Overview – WebMD

Orthognathic Surgery: Background, History of the Procedure …

As relevant skeletal and neurovascular anatomy can be found in many anatomic atlases, this section focuses on specific aspects pertinent to the procedures described.

With maxillary osteotomies, an understanding of the vascular blood supply to the mobilized maxilla is crucial. The arterial blood supply to the maxilla is derived from 4 primary sources: (1) the descending palatine branch of the maxillary artery, (2) the ascending palatine branch of the facial artery, (3) the anterior branch of the ascending pharyngeal artery from the external carotid, and (4) the alveolar branches of the maxillary artery. With complete mobilization of the maxilla, frequently the descending palatine vessels are disrupted and the mobilized maxilla derives its vascularity from the remaining sources, primarily the ascending palatine and pharyngeal vessels.

To avoid neurosensory deficits with mandibular osteotomies, the surgeon must be cognizant of the course of the inferior alveolar nerve from its entrance at the mandibular foramen on the medial aspect of the ramus to its emergence from the mental foramen between the first and second premolars. Vertically, the mandibular foramen typically lies approximately 8 mm inferior to the lingula mandibularis (the anterior wall of the mandibular foramen), and the lingula is approximately 5 mm above the occlusal plane. With the sigmoid notch as a reference point, the foramen is approximately 20 mm inferior. Regarding the anterior-to-posterior relationship, the foramen is located 20 mm from the anterior mandibular ramal border, a depth of approximately two thirds of the total mandibular ramal width.

The canal then courses within the mandible, measuring 2-2.5 mm in diameter. Its lowest point from the inferior mandibular border is in the region of the first and second molars, approximately 7.5 mm, before continuing anterior and superior to its emergence from the mental foramen, where it is approximately 8 mm from the inferior border. At the mental foramen, the canal extends caudally before emerging. Regarding the transverse position of the canal within the mandible, it is most superficial in the region of the third molar, approximately 2 mm from the buccal plate. In the region of the first molar, it is 4 mm from the buccal plate.

A number of basic dental concepts pertinent to orthognathic surgical procedures are important.

Universal Dental Notation is the most common system for numerically identifying permanent dentition. The maxillary dentition is numbered sequentially from 1-16 starting with the right maxillary third molar as 1. The numbering system continues from 17-32 beginning with the left mandibular third molar as 17.

Orientation with respect to intraoral anatomy is referenced to the following terms:

Mesial – Toward the dental mid line

Distal – Away from the dental mid line

Labial – Toward the lips

Buccal – Toward the cheek

Apex – Toward the root tip

Lingual – Toward the tongue

Incisal – Toward the biting surface (anterior dentition)

Occlusal – Toward the biting surface (posterior dentition)

Angulation – Mesiodistal tipping of the long axis of the tooth

Inclination – Labiolingual or buccolingual tipping of the long axis of the tooth

See the list below:

Cusp – Pronounced elevation on the occlusal surface

Groove – Depression on the occlusal surface

Crown – Visible portion of the tooth covered by enamel

Cingulum – Bulbous convexity of the cervical one third of the lingual surface of anterior dentition

Cervix (neck) – Junction of the crown and root

Root – Portion of the tooth covered by cementum within the alveolar bone

Curvature of the dental arches – Normal reciprocal curvature in the dental arches with the maxilla convex and the mandible concave (allows the dentition maximal contact during function)

Curve of Spee – Normal curvature of the dental arch in the sagittal plane

Curve of Wilson – Normal curvature of the dental arch in the coronal plane

The classification of dental occlusions is based on Edward Angle’s observation in 1899 that the key to occlusion is the relationship of the mandibular first molar to the maxillary first molar. [2]

Angle’s original classification has been expanded to include the anterior dentition. Class II is subdivided further to include the angulation of the anterior dentition. In Class II, Division 1, the molar relationship is Class II, but the maxillary anterior teeth are flared labial. In Class II, Division 2, the molar relationship is Class II, but both the maxillary and mandibular anterior teeth are retruded with a deep bite. The terms Class I, II, and III also are used to relate the maxillary and mandibular canine relation.

The Angle classification relates only to maxillary dentition with the mandibular dentition. While it generally is assumed that a similar skeletal relationship of Class I, II, and III follows, this is not always the situation. A Class I molar relationship is possible with a Class II skeletal relationship by dental extractions and orthodontic alignment without regard to basal skeletal morphology.

Additional terms are used to describe the relationship between the dentition of the upper and lower arches.

Overjet – Horizontal distance between the incisal edges of the maxillary incisor to the mandibular incisor

Overbite – Vertical distance between the incisal edge of the maxillary incisor and the mandibular incisor

Crossbite – Lingual-buccal malposition of the normal relationship between the upper and lower dentition (negative overjet)

Deep bite – Condition of excessive overbite

Open bite – Condition of negative overbite (teeth do not meet)

The anterior dentition typically inclines so as to partly offset the malocclusion and may allow some degree of anterior occlusion to occur depending on the maxillary-mandibular discrepancy. In prognathism, the lower incisors may be flared lingual and the upper incisors flared labial to compensate for the Class III malocclusion. Conversely, with mandibular deficiency the opposite occurs; the mandibular dentition is flared labial and the maxillary dentition flared lingual.

Centric relation is the most retruded position of the condyle within the glenoid fossa (terminal hinge position). It refers to the condylar-glenoid fossa relation but does not indicate the occlusion. Centric occlusion indicates the maximum intercuspal contact of the dentition and does not refer to the condylar position. In the ideal situation, when the patient is in centric occlusion (maximum), the condylar-glenoid is in proper centric relation.

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Orthognathic Surgery: Background, History of the Procedure …

Orthognathic | Orthognathic Jaw Surgery | Orthognathic Surgeon

Orthognathic surgery is needed when jaws dont meet correctly and/or teeth dont seem to fit with jaws. Teeth are straightened with orthodontics, and corrective jaw surgery repositions misaligned jaws.

Orthognathic:Orthognathic surgery might be required when the jaws also need repositioning. Difficulty in the subsequent areas is to be evaluated: difficulty in chewing, biting or swallowing speech problems chronic jaw open bite protruding jaw breathing problems obstructive sleep apnea receded jaw.

Orthognathic Jaw Surgery:”Who Needs Jaw Surgery? People who may benefit from jaw surgery include those with an improper bite or jaws which are positioned incorrectly. Jaw growth is really a gradual process and, in some instances, the upper and lower jaws may grow at different rates. The result can be a host of troubles that can affect chewing function, speech, long-term oral health, and appearance. Injury to the jaw and birth defects will also affect jaw alignment. ”

Orthognathic Surgeon:Pressure coming from erupting teeth or changes in jaw growth may move other teeth and disrupt the orthodontic or natural alignment of teeth. A good surgeon can resolves those issues. Early removal or corrections are recommended in order to prevent such future problems and then to decrease the surgical risk linked to the procedure.

Dental Implants:Dental implants are changing the way people live! These are created to provide a foundation for replacement teeth which look, feel, and performance like natural teeth.

orthognathic@orthognathic1.com

Orthognathic Jaw Surgery Article:

“Orthognathic surgery is required when jaws dont meet correctly and/or teeth dont appear to fit with jaws. Teeth are straightened with orthodontics, and corrective jaw surgery repositions misaligned jaws. This not only improves facial appearance, but also ensures that teeth meet correctly and performance properly. Who Needs Jaw Surgery? Individuals who may benefit from jaw surgery include those with an improper bite or jaws which are positioned incorrectly. Jaw growth is a gradual process and, in some instances, the upper and lower jaws may grow at different rates. The result could be a host of problems that can affect chewing function, speech, long-term oral health, and appearance. Injury to the jaw and birth defects will also affect jaw alignment. While orthodontics alone can correct bite problems only when the teeth are involved, orthognathic surgery might be required in case the jaws also need repositioning. Difficulty in these fundamental areas should really be evaluated: difficulty in chewing, biting or swallowing speech problems chronic jaw open bite protruding jaw breathing problems obstructive sleep apnea receded jaw any of such can exist at birth or may be acquired after birth as a result of hereditary or environmental influences or, trauma into the face. Before any treatment begins, an afternoon will certainly be held to play comprehensive examination with x-rays. In the course of the pre-treatment consultation process, it s a good idea to ask any questions that you have regarding your treatment. When you’re fully informed about the aspects of this care, mom and her dental team will likely make the options to proceed with treatment together. Our doctors uses modern computer techniques and three-dimensional models to display you exactly precisely how the surgery will certainly be approached. Using comprehensive facial X-rays and computer video imaging, we can easily let you your bite will be improved and present you with the south beach diet plan of how you’ll take care of surgery. This helps you understand the surgical process along with the extent of a typical treatment prescribed, and also to consult the benefits of jaw surgery. For a candidate for Corrective Jaw Surgery, our doctors would work closely with your dentist and orthodontist during your treatment. The very surgery can move your teeth and jaws inside new position that gives you a more attractive, functional and healthy dental-facial relationship.”

Orthognathic Jaw Surgery

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16: Complications Associated with Orthognathic Surgery …

No matter how accurate the diagnosis and how meticulous the surgeon, complications will occur after orthognathic procedures.* Alternatively, the relative safety of orthognathic procedures has been confirmed by a number of retrospective reviews.13,32,84,93,152,223,245,254,315,353 Panula and colleagues reviewed maxillary and mandibular osteotomy patients at their institution (N = 655) and found only one serious complication (intraoperative bleed). A prospective study of Le Fort I operations by Kramer and colleagues (N = 1000) found a 6.4% incidence of complications that ranged from extensive bleeding (1.1%) to sensory loss in the distribution of the infraorbital nerve.173 A review by Chow and colleagues of a consecutive series of orthognathic patients (N = 1294) documented a relatively high complication rate (9.7%)61; this included mostly manageable postoperative infections (7.4%), with no serious or rare events recorded. A large series of orthognathic patients (N = 2049) was reviewed by Van de Perre and colleagues346; those authors identified one patient death and 44 other patients with either primary or secondary complications.

The definition of what constitutes a complication in orthognathic surgery varies between both researchers and clinicians, thereby making interstudy comparison difficult. By understanding the medical history and physical findings of the individual who presents with a dentofacial deformity including 1) an awareness of any associated conditions or malformations 2) the patients baseline psychosocial health and 3) any head and neck dysfunctionspatient-specific complications can be minimized. A thorough informed consent process should also focus on patient-specific and family-centered issues. The patients specific risk factors should be presented to the individual and his or her family for consideration before treatment.

An essential part of risk assessment includes the surgeons performance of a thorough review of the patients medical records and the completion of a history and physical examination. A general clearance examination by the patients pediatrician or general physician and further confirmation of the patients health through appropriate laboratory testing is also important. The pregnancy testing of females of childbearing age should be performed routinely the morning of surgery.

For middle-aged adults who are considering orthognathic surgery, additional medical risk factors may include cardiovascular disease; obesity or increased body mass index; obstructive sleep apnea; diabetes; pulmonary disease; smoking history; the potential for deep vein thrombosis or pulmonary embolus; and osteoporosis or the use of bisphosphonate treatment (see Chapter 25).30,50,172 Evaluation by the patients primary care physician (and, in many cases, by other medical specialists) and appropriate laboratory work (e.g., electrocardiography, chest radiography, chemistries, hematology, thyroid tests, coagulation studies) help to identify areas of concern. The adult patient with an elevated body mass index who is undergoing surgery is at greater than average risk for intraoperative and postoperative complications. The presence of obstructive sleep apnea in the patient with a jaw deformity should be considered and ruled out (see Chapter 26).

Specific patient factors that may impair wound healing include diabetes mellitus, smoking, bisphosphonate treatment for osteoporosis, poor nutritional status, and chronic glucocorticoid exposure. Type II diabetes mellitus is frequently a comorbidity of obesity and increased body mass index. Alpha and colleagues documented a 66% incidence of postoperative infections among diabetic patients undergoing maxillary or mandibular osteotomies, despite adequately controlled glucose levels.9

The inhalation of nicotine via cigarettes affects both pulmonary function and wound healing.72,75,95,264,137,149,176 Smoking or nicotine ingestion has been shown to delay the chondrogenic phase of bone (osteotomy) healing and to decrease the circulation of surgically elevated flaps, thereby resulting in impaired healing after wound closure. Cigarette smoke contains nicotine, carbon monoxide, and hydrogen cyanide; each of these chemicals has been shown to impair wound healing by producing relative tissue hypoxia. Nicotine is a vasoconstrictor that diminishes tissue oxygenation, predisposes the individual to microvessel thrombosis (i.e., increased platelet adhesion and direct endothelial cell damage), and diminishes cell proliferation and function. Carbon monoxide reduces oxygen-carrying capacity, and hydrogen cyanide inhibits oxidative metabolism and oxygen transport. These consequences of cigarette smoke tissue ischemia are most evident during healing after surgical procedures, when tissue circulation is at risk for interruption (e.g., after microvascular tissue transfer, during the placement of free [non-pedicled] bone grafts). A number of clinical studies have documented increased morbidity in patients who smoke and later undergo head and neck reconstructive and aesthetic procedures. To minimize postoperative wound difficulties and anesthesia-related pulmonary complications, patients should be counseled to refrain from smoking for at least 6 to 8 weeks preoperatively and for 2 to 4 weeks postoperatively. A serum or urine nicotine concentration can be obtained before surgery to confirm patient compliance.

It is known that bisphosphonate treatment for osteoporosis can affect osteoclast activity and that it may negatively impact successful bone healing. Current guidelines concerning bisphosphonate treatment continue to evolve and should be followed when planning jaw or dentoalveolar procedures.1,85,125,198,209,214,215,220222,248,283,285,292,294,357,367

Perioperative risk to the airway and its management should be considered during all phases of surgical care, including before nasotracheal intubation, during surgery, at the time of extubation, and soon after extubation (Fig. 16-1).53,61,76,170,175,250 The basic clinical preoperative airway assessment should include 1) measurements of mandibular range of motion (i.e., vertical opening and protrusion); neck mobility 2) Mallampati classification 3) the ratio of the patients height to the thyromental distance 4) neck circumference and 5) body mass index. A Mallampati classification of III or IV or a ratio of height to thyromental distance of more than 23.5 is a strong indicator of a difficult airway with conventional direct laryngoscopy. A neck circumference of more than 17 inches in men is a risk factor for obstructive sleep apnea. Individuals who are scheduled to undergo orthognathic surgery may have special medical risk factors that include baseline malformations or syndromes and associated abnormalities that carry the potential for difficult airway control (see Chapter 11). In the high-risk patient, advance discussion with the anesthesia team to arrange for an anesthesiologist who is experienced with difficult away management and who is skilled with awake fiber-optic intubation may be indicated (see Fig. 16-1) (Video 5). After the nasotracheal tube is in place, the surgeon secures it and assists with its management during the operation (see Chapter 15). Complications associated with endotracheal tubes that are placed for orthognathic procedures have included herniation of the airway tube cuff leading to occlusion of the tube lumen; inadvertent surgical sectioning of the endotracheal tube; and the occurrence of contact granuloma of the vocal cords.62,249 Acute intraoperative or postoperative pulmonary edema, postoperative apnea, pneumomediastinum, and pneumothorax have all been reported as complications associated with anesthesia (see Chapter 11).14,33,34,56,91,117,122,153,217,233,245,259,318,321

Malignant hyperpyrexia involves an abnormality of muscle metabolism of genetic origin that manifests as widespread skeletal muscle contraction, hypercatabolism, and hyperthermia upon exposure to volatile anesthetic agents or succinylcholine.192,223,365 It is a serious condition that requires prompt diagnosis and aggressive management. It may occur during an orthognathic procedure with a typical initial intraoperative presentation of tachycardia and noticeably warm skin.

Decisions about the timing of extubation after surgery should be made by clinicians on the basis of extubation criteria and patient-specific risk factors.159,376 In general, the surgeon is present at the time of extubation in case either emergency tracheostomy or reintubation is required. Our preference is to extubate the patient in the operating room when feasible but only when specific parameters are met. For the patient with an ongoing difficult airway, a more delayed approach to extubation maybe taken. The risk of inadequate ventilation after extubation is highest when pre-extubation parameters are not adequately met and when excess sedation remains (see Chapter 11).

Spontaneous leg compartment syndrome has been reported as a complication after orthognathic surgery.204 The occurrence is thought to be the result of a drug interaction between anesthetic or postoperative medications or the effect of antidepressive drugs that are superimposed on chronic mild exercise-induced compartment syndrome.

Death is recognized as an exceedingly rare complication related to orthognathic procedures. Of the numerous large case series published, only one death has been described; this was reported by Van de Perre and colleagues from a series of 2049 patients.210 It occurred in a 17-year-old male patient who was described as being slightly mentally challenged and who underwent bimaxillary osteotomies. Six hours postoperatively, a cardiac arrest occurred, and attempts to resuscitate the patient failed. The cause was thought to be preexisting cardiomyopathy. A death was also reported by Waack and colleagues as part of a limited series of 63 consecutive Le Fort I osteotomies.216 The death occurred in a healthy 15-year-old female patient on the first postoperative day as a result of unknown causes.

As part of the presurgical assessment, the evaluation of the patients cervical spine is essential. Congenital malformations, previous trauma, and arthritis are occasional etiologies of cervical spine problems in the orthognathic patient. Patients with specific syndromes (e.g., KlippelFeil anomaly, hemifacial microsomia, Treacher Collins syndrome, Apert syndrome) are at higher risk for a cervical spine malformation that may be undiagnosed at presentation to the orthognathic surgeon (see Fig. 16-1). Referral for evaluation by an orthopedic spine surgeon, a neurosurgeon and a geneticist as well as appropriate radiographic studies (e.g., magnetic resonance imaging, computed tomography) are carried out when indicated. Controlled positioning with limited flexion, extension, and rotation at the time of intubation, intraoperatively, and during recovery may be required. In some cases, intraoperative neuro-monitoring (e.g., motor and sensory) is useful to confirm minimal spinal compression during surgery.

To minimize patient and family disappointment after surgery, an informal (or, in some cases, a more rigorous) psychosocial assessment is conducted.24,36,73,81,167,304,317 All parties involved must accept the risks and limitations of the planned surgical procedures. Unfortunately, neither the preoperative psychosocial assessment nor the individuals biologic wound-healing ability is completely predictable. A small percentage of patients will perceive an unfavorable surgical outcome, even when the clinicians feel that the results are at least satisfactory. Others will not accept a complication, even though the risks were fully explained in advance and all precautions were taken.

Body dysmorphic disorder is a medical condition that can be difficult to recognize before surgery but that will routinely result in postoperative patient dissatisfaction. It is estimated that 7% to 15% of individuals who pursue cosmetic surgery have body dysmorphic disorder (see Chapter 7).

The orthognathic surgeon should evaluate the patients baseline head and neck functions, including speech, swallowing, mastication, neck and mandibular range of motion, breathing, hearing, vision, cognition, and psychosocial competence. Any of these functions may be negatively affected by the presenting maxillofacial deformity or malformation and influenced (either favorably or unfavorably) by the treatment being contemplated.94,113,139,163,228,232,311,313,320,377 A candid discussion with the patient and the family about the potential impact of the planned procedures on any of these functions should take place before treatment.

Limiting risks and complications requires an informed patient and family, coordinated collaborative comprehensive clinical care, an experienced and focused surgeon, meticulous planning, a dedicated operating room team, effective postoperative hospital care, and appropriate outpatient management. The operating room team includes the surgeon and his or her assistants, the anesthesiologist and his or her assistants, the operating room personnel (e.g., scrub nurse/technician, circulating nurse), and the full complement of sterilized and organized instrumentation (e.g., inventory, sanitation and sterilization personnel). The instrumentation includes power saws and drills, with their associated bits and blades; handheld instruments; and fixation hardware such as plates and screws. Specific medications, sutures, and dressing materials are also required. The confirmation of the prepared operating room team, equipment, instrumentation, and medications should be undertaken before the patient enters the operating room. The anesthesiologist and the surgeon should discuss the patients airway and his or her intraoperative and postoperative needs before entering the operating room (see Chapter 11). After the equipment, instrumentation, and medications are set up and checked and the team is briefed, the patient may enter the operating room with the best opportunity for success.

Historically, the presence of impacted third molars during a sagittal ramus osteotomy (SRO) of the mandible has been presumed to be associated with increased complications including the following: 1) a higher incidence of bad splits 2) a higher incidence of infection 3) issues with the placement of fixation (i.e., osteotomy stabilization) and 4) difficulties maintaining the integrity of the inferior alveolar nerve (IAN). It is for these reasons that, in the past, the removal of impacted mandibular third molars 6 to 12 months before an SRO was routinely recommended. However, the arguments against this approach are that this subjects the patient to two surgeries, two anesthetic treatments, and two recovery periods rather than just one and that this staged approach may in fact increase rather than decrease the previously mentioned complications.

Clinical studies have now documented no increased risk of unfavorable or so-called bad splits when SROs are performed in patients with impacted third molars as compared with those without third molars.90,218,268,276,348 Doucet and colleagues laid this argument to rest with their prospective cohort study that looked at the effects of the presence or absence of third molars during SRO on 1) the frequency of unfavorable fractures 2) the degree of entrapment of the IAN in the proximal segment and 3) the procedural time required to move the teeth.89 The study included patients who were scheduled to undergo SRO to correct a dentofacial deformity. Study patients were divided into two subgroups: Group I was made up of those with an impacted mandibular wisdom tooth at the time of SRO (n = 331; mean age, 19.6 years); Group II included those without a mandibular wisdom tooth at the time of SRO (n = 346; mean age, 30.4 years). The overall incidence of unfavorable fractures was 3.1% (21 out of 677), with frequencies of 2.4% (8 out of 331) in Group I and 3.8% (13 out of 346) in Group II. Interestingly, the rate of IAN entrapment in the proximal segment was significantly lower in Group I (37.2%) than in Group II (46.5%). The removal of third molars at the time of SRO increased procedural time by only 1.7 minutes.

Note:

When the removal of impacted mandibular third molars is recommended to the patient for long-term dental health, it is generally this authors preference to do so at the time of orthognathic surgery (Fig. 16-2, A).

As documented in published studies, this author has not experienced increased levels of complications (e.g., infection, bad split, inability to place fixation, increased incidence of inferior alveolar paresthesia) by doing so.

Exceptions to the routine removal of impacted wisdom teeth at the time of orthognathic surgery may include a severely hypoplastic mandible that requires extensive advancement (i.e., in certain patients with hemifacial microsomia or Treacher Collins syndrome). In such cases, maximal ramus region bone stock is needed for osteotomy stabilization and healing. For those few patients, the preoperative removal of the wisdom teeth followed by adequate time for sufficient bone fill (i.e., 12 months) may be preferred.

When the removal of erupted or partially erupted mandibular wisdom teeth is carried out at the time of SRO, the standard vestibular incision for SRO is altered to achieve access to the erupted wisdom teeth and then for watertight wound closure (Fig. 16-2, B) (also see Chapter 15). In review, when considering evidence-based medicine, the routine practice of the removal of wisdom teeth before SRO can no longer be justified.

When removing impacted maxillary wisdom teeth, access through the floor of the antrum after down-fracture at the time of Le Fort I osteotomy represents this authors usual approach (Fig. 16-2, C). The exception is when carrying out segmental osteotomies in a cleft maxilla in conjunction with extensive horizontal advancement of the lesser segment. In these cases, the removal of the wisdom tooth in the lesser segment may significantly diminish bone volume with potential compromise of stabilization and healing.

The removal of an erupted or partially erupted maxillary wisdom tooth is completed through the gingival opening before down-fracture. When this is done, minimal flap elevation is essential so as not to compromise maxillary perfusion after down-fracture.

Metal plates and screws have been used to stabilize fractures and osteotomies in the maxillofacial region for more than 40 years.8,9,12,39,46,47,104,131,151,164,225,281,336 The metals that were initially used were stainless steel and vitalium; these were followed by titanium and its alloys.

There is both laboratory and clinical evidence of the tissue compatibility and the high corrosion resistance of titanium and its alloys in the human body. In 1991, the Strasbourg Osteosynthesis Research Group recommended that the removal of a non-functional plate is desirable provided that the procedure does not cause undue risk to the patient.32A,355A During earlier years, those who were advocating the routine removal of fixation devices after stable bone union felt that the implant had significant potential to cause problems, so its removal was considered preventative. Today, clinicians agree that the medical risk and financial costs incurred by the routine removal of asymptomatic fixation hardware cannot be justified. It is currently standard practice to remove fixation plates and screws only when clinically indicated.

Becelli and colleagues completed a retrospective analysis of complications of bicortical screws used for sagittal split ramus osteotomy (SSRO) fixation.22 The authors reviewed a consecutive series of patients (N = 241) who were undergoing sagittal ramus osteotomies (N = 482) for skeletal Class III deformities. Complications related to bicortical titanium screws were observed at 3% of the osteotomy sites (Fig. 16-3). The hardware was eventually removed in these patients (15 out of 482), without long-term consequences.

Note:

In this authors personal series of orthognathic procedures from more than 27 years of clinical practice, the need to or a request by the patient to remove a plate or screw after healing has involved less than 2% of individuals (Fig. 16-3).

The indications for removal fall into the following categories: 1) a palpable and bothersome piriform aperture plate or screw at the Le Fort I osteotomy site when the skin is compressed against it with a finger; 2) a palpable and bothersome zygomatic buttress plate when a food bolus compresses against it while chewing; 3) an exposed bicortical screw head in the labial vestibule at the SSRO site; 4) a screw in close contact with a dental root that is symptomatic; and 5) a bicortical screw that extends through the lingual cortex of the ramus and that causes discomfort or concern, either during movement of the tongue or upon contact with food during swallowing. Under these circumstances, the elective removal of the involved plate or screw is carried out after osteotomy healing has occurred (i.e., preferably 6 to 12 months after surgery).

The use of self-reinforced biodegradable bone plates and screws has been advocated for use in orthognathic surgery by a limited number of surgeons throughout the world.92,96,127,130,155,165,178,297,325,344,345 Although this type of fixation is appealing in theory, a greater incidence of postoperative complications has been found with resorbable fixation devices as compared with titanium. Furthermore, no advantages in the achievement of improved skeletal stability have been documented with the use of biodegradable hardware.

Turvey and colleagues reported about 70 patients who were undergoing 194 osteotomies of the maxilla or the mandible and who were stabilized with self-reinforced polylactate bone plates or screws of similar size and configuration to those of titanium systems.344 The placement of the devices was accomplished transorally and transfacially in a way that was consistent with the osteotomy location. Maxillomandibular elastics were used for each patient after surgery to control the position of the jaws. Three out of the 70 patients (4%) experienced immediate postoperative loosening of the resorbable bone screws. Each of the patients required a return to the operating room for more rigid stabilization at the involved osteotomy site. Although all patients eventually achieved acceptable occlusion, a number of fixation sequelae occurred during the healing phase, including prolonged mobility of the maxilla; sterile abscess requiring debridement; swelling with sterile fistula tract formation; and intranasal inflammation requiring fixation removal at the time of secondary septoplasty. Although the authors demonstrated that biodegradable plates and screws could be used for orthognathic surgery, there was no advantage when this was compared with titanium fixation devices, and the complication rate is increased.

In a second study, Turvey and colleagues reported about 69 patients who were undergoing sagittal split ramus osteotomies for mandibular advancement.345 Thirty-four of these patients underwent fixation with self-reinforced biodegradable screws, whereas 35 patients underwent fixation with 2-mm titanium screws. Postoperatively, one of the patients with biodegradable screws required a return to the operating room for improved fixation. Again, no advantage could be demonstrated with the use of biodegradable fixation, whereas a degree of diminished levels of stabilization and increased complications were shown to be present.

Ahn and colleagues completed a study to evaluate the complications of resorbable versus nonresorbable plate and screw fixation in orthognathic surgery.3 Patients were enrolled in the prospective study (N = 272). Titanium plates and screws were used at the osteotomy sites in Group I (N = 152), and resorbable plates and screws were used at the osteotomy sites in Group II (N = 120). In the 152 patients with titanium plates and screws, there was a complication rate of 8.6% (N = 13). Of the 120 patients with resorbable plates and screws, 18.3% (N = 22) developed complications. There was a greater degree of postoperative infections and malocclusions and a trend toward relapse observed in patients with resorbable plate and screw fixation. Three of the patients with resorbable plate and screw fixation required reoperation for residual malocclusion as compared with zero in the titanium group.

Infection after orthognathic surgery is considered by most to be uncommon. However, a review of the literature indicates a wide range in the reported incidence of this complication.* A critical review of these studies provides insight into the true incidence of infection, clinical pitfalls to consider, and methods to use to best limit these sequelae.

All transoral wounds must be considered clean-contaminated wounds, with an anticipated theoretical infection rate of as high as 15%.352 It is said that this incidence of infection in a clean-contaminated site can be reduced to as low as 1% with good surgical technique and the appropriate use of prophylactic antibiotics. The question remains of how to best provide this type of antibiotic coverage for the orthognathic surgery patient. According to the infectious disease literature, antibiotic prophylaxis should provide adequate drug levels in the tissue before, during, and for the shortest possible time after surgery to provide a reduced infection rate; be an effective agent against the bacteria that are most likely to cause the infection; and be bactericidal while at the same time being the least toxic agent available.

Spaey and colleagues reported a 4% prevalence rate of infection after orthognathic procedures in their cohort.312 Among the infections that were sustained, 92% occurred at the SSRO site, 1% occurred at the Le Fort I osteotomy site, and only 0.5% involved the chin osteotomy location (Figs. 16-4 through 16-7). In their pilot study group, after completion of an SSRO, the authors placed a drain through the mandibular vestibule mucosa incision; this was removed the following morning. The prophylactic antibiotic regimen that was initially used did not have a drug level in place while the drain remained in or after its removal. Because of the high infection rate observed in the pilot study, the researchers changed the protocol to no longer involve the placement of a drain; to achieve a more meticulous mucosal wound closure; and to extend the time of prophylactic antibiotic use to 5 days after surgery. As a result, the infection rate at the SSRO site was dramatically decreased. The authors concluded that, in addition to an extended use of prophylactic antibiotics, the achievement of a sealed vestibular wound at the SSRO is essential to limit the infection rate.

Figure 16-4 A woman in her early 30s with a primary mandibular deficiency growth pattern underwent a comprehensive orthodontic and surgical correction. This required the removal of dental compensation, including opening upper bicuspid extraction spaces for dental implants. Surgery included bilateral sagittal split ramus osteotomies, an osseous genioplasty, and anterior neck soft-tissue procedures. In-hospital and early at-home convalescence proceeded without incident. Five weeks after surgery, the patient returned to a more normal diet, to regular physical activities, and to her orthodontists care. Two months after surgery, pain in the left mandibular second molar region with chewing was persistent. The tooth was also tender to percussion. A periapical radiograph revealed the proximity of a bicortical fixation screw to the distal root, with possible apical root resorption. The removal of the involved screw was offered. However, the patient chose root canal therapy followed by the relief of pain and the resolution of percussion tenderness. A, Profile and lateral cephalometric views before treatment. B, Oblique facial views before and after treatment. C, Pretreatment and posttreatment lateral cephalometric radiographs. D, Left side Panorex image 2 months after surgery, with left mandibular second molar pain with chewing. E, A periapical radiograph is shown before and after successful root canal therapy (see Fig. 19-8).

Figure 16-5 A 23-year-old man with a developmental jaw deformity and malocclusion was referred for surgical evaluation. He had also recently sustained trauma to the maxillary anterior region that involved a loss of the central incisors. The jaw deformity was characterized by maxillary deficiency in combination with relative mandibular excess. The patient agreed to a comprehensive surgical and dental rehabilitative approach. He also had lifelong difficulty breathing through his nose. After periodontal and restorative evaluations, the patient underwent orthodontic (dental) decompensation. Surgery included maxillary Le Fort I osteotomy in segments (arch expansion, horizontal advancement, and cant correction); bilateral sagittal split ramus osteotomies (asymmetry correction); osseous genioplasty (horizontal advancement); and septoplasty and inferior turbinate reduction. In-hospital and initial at-home convalescence proceeded without difficulty. Three weeks after surgery, increased swelling and tenderness along the right ramus region were appreciated, and intraoral drainage through the lateral ramus incision was recognized. The patient underwent exploration with Penrose drain placement as an office procedure under local anesthesia, and he was restarted on antibiotics. The drain was removed 1 week later, and the 10-day course of oral antibiotics was completed. Healing at all osteotomy sites remained on track. Five weeks after surgery, the patient returned to a more regular diet and physical activity without delay. The orthodontic appliances were removed 6 months after surgery. A, Presurgical facial and occlusal views with orthodontics in progress. B, Profile and lateral cephalometric views before surgery. C, Articulated dental casts that indicate analytic model planning. D, Three week postoperative lateral cephalometric radiograph. E, Three week postoperative Panorex radiograph. F, Facial and occlusal views 3 weeks after surgery at the time of persistent right facial swelling and intraoral drainage. The patient underwent exploration and Penrose drain placement.

Figure 16-7 A 20-year-old college student with an asymmetric mandibular excess growth pattern (Hemi-mandibular elongation) arrived for surgical evaluation. She had previously undergone orthodontic attempts to neutralize the occlusion without success. She agreed to a combined orthodontic and surgical approach. With the removal of orthodontic (dental) compensation, surgery was carried out. The procedures included bilateral sagittal split ramus osteotomies (asymmetry correction) and osseous genioplasty (horizontal advancement). By 5 weeks after surgery, postoperative swelling had generally subsided. A painless lymph node was palpable in the right submandibular region. It was not fixed to the skin or bone. Three months after surgery, what appeared to be a localized lymph node became tender with erythema and then with drainage through the skin. Cultures were carried out and showed no specific growth. An infectious disease consult was obtained, and Gram staining showed gram-positive rods. The patient was placed on amoxicillin and then Augmentin. The localized infection involved intermittent drainage but without a connection down to the bone. Four months after surgery, the patient agreed to undergo excision of the soft-tissue mass with primary closure and the reinstituting of antibiotics. Histopathology was unremarkable, and the cultures remained negative. The wound healed without complications. A, Facial and occlusal views with orthodontics in progress. B, Articulated dental casts that indicate analytic model planning. C, Facial views with smile before and 5 weeks after surgery. D, Lateral cephalometric radiographs before and 5 weeks after surgery. E, Panorex radiographs before and 5 weeks after surgery. F, Right submandibular localized infection demonstrated by 3 months after surgery. G, Four months after surgery, the soft-tissue infection was excised and sent to the pathology and bacteriology departments. H, Frontal views with smile before and after successful treatment. I, Occlusal views before retreatment, just before surgery, and then after successful treatment. J, Right oblique facial views before and after successful treatment. K, Right profile views before and after successful treatment.

In a randomized, double-blind study, Ruggles and colleagues tested two different antibiotic regimens in patients undergoing orthognathic surgery.284 Both groups received preoperative and intraoperative antibiotics, whereas only one group continued 48 hours of postoperative coverage. The group that received no postoperative antibiotics had a 15% infection rate, whereas no infections were found in the group with extended antibiotic coverage.

Danda and colleagues completed a prospective study to evaluate the use of prophylactic antibiotics among patients who were undergoing orthognathic surgery.78 The study patients (N = 150) were divided into two groups. Group I (N = 75) received a single dose of antibiotic prophylaxis. Group II (N = 75) received a full day of antibiotic prophylaxis. In Group I, 9.3% of patients (N = 7) developed infection, whereas only 2.6% (N = 2) of Group II patients did. The results indicate a clinically significant increased rate of infection with single-dose antibiotic prophylaxis as compared with a full day of antibiotic prophylaxis.

Kublefelt and colleagues reported on smoking as a significant risk factor for infection after orthognathic surgery.176A This was a retrospective cohort study of individuals (n = 286) who were undergoing one-jaw orthognathic surgery (i.e., bilateral SSRO [BSSRO] or Le Fort I osteotomy) during a 7-year period. All patients received a 1-week course of antibiotics. Patients ranged in age from 17 to 56.5 years (mean, 34.8 years). The overall infection rate was 9.1%. The only statistically significant identified risk factor for infection in these study groups was smoking history. The incidence of infection was 14.4% among smokers and 7.0% among non-smokers. The site of infection was primarily the ramus region followed by the Le Fort I osteotomy region.

Interestingly, six cases of actinomycosis after orthognathic procedures have been reported.216,293 Ozaki and colleagues reported a case of actinomycosis that occurred in the left submandibular area after SSRO.249 The infection resolved after 2 months of antibiotic therapy.

Note:

Current literature confirms that, for orthognathic surgery that includes SSRO, the following are true: 1) prophylactic antibiotics (preoperative, intraoperative, and postoperative) reduce infection rates 2) effective wound closure (without occurrence of dehiscence) will diminish infection rates 3) intraoral drains placed at the osteotomy site are counterproductive and 4) the incidence of infection is higher among smokers.

When completing an SRO, an unfavorable fracture (i.e., a bad split) can occur.23,42,139,162,206,243,334 The definition of a bad split varies from clinician to clinician. This author reserves the term bad split only for those SROs in which the condyle either remains with the distal segment, thus requiring a separate osteotomy (i.e., third piece), or shatters into a separate component (i.e., third piece) on its own (Fig. 16-9). Other less than ideal splits may include the following: 1) a separate fracture or piece of the buccal plate 2) a separate fracture or piece of the lingual plate posterior to the second molar; or 3) a separate fracture or piece of the coronoid process. All three of these splits are generally manageable without alteration of the expected postoperative recovery. When the buccal plate separates from the proximal segment, the fragment is either removed or additional plate and screw fixation is used to secure it. When the lingual plate separates from the distal segment, no additional fixation is generally required. The lingual bone fragment is either removed or left in place. When the coronoid process separates from the proximal segment, it is usually removed to limit the chance of ankylosis during the healing process.

Figure 16-9 A woman in her mid 40s was referred for the surgical evaluation of asymmetric mandibular deficiency with secondary deformities of the maxilla. A longstanding flattening of the left condylar head with a loss of posterior facial height was felt to be responsible. There were no current symptoms of temporomandibular disorders, and the condyle was felt to be stable. The patient had an asymmetric Class II excess overjet anterior open-bite malocclusion. An orthodontic and surgical approach was selected. With orthodontic (dental) decompensation complete, surgery included maxillary Le Fort I osteotomy in segments (arch expansion and cant improvement); bilateral sagittal split ramus osteotomies (minimal horizontal advancement and asymmetry improvement); osseous genioplasty (horizontal advancement); redo septoplasty; and neck liposuction. During surgery, a bad split was appreciated on the left side. Nevertheless, the ramus osteotomy was secured with three bicortical screws. Radiographs the day after surgery confirmed a separate condylar component in the left ramus region. Posteroanterior and lateral cephalometric and Panorex radiographs were again taken 10 days after surgery, and these were suggestive of adequate segment approximation. At 5 weeks after surgery, left lateral mandibular facial swelling with mild tenderness persisted. At 8 weeks after surgery, a left posterior mandibular vestibular fistula was appreciated. In the operating room, the wound was opened to remove a buccal shelf and coronoid fragment as well as the fixation screws. Cultures confirmed Escherichia coli, Enterobacter, alpha-hemolytic Streptococcus, and Candida. Oral antibiotics were initiated, including clindamycin, ciprofloxacin, and Diflucan. At 11 weeks after surgery, there was a functional occlusion with good vertical mouth opening and a mild shift to the left. At 9 months after surgery, facial morphology and occlusion remained acceptable, and the orthodontic appliances were removed. A, Facial and occlusal views with orthodontics in progress. B, Profile and lateral cephalometric views before surgery. C, Panorex radiograph before surgery that indicates longstanding left condylar head flattening with an intact cortical rim. There is mandibular deficiency and a shift to the left. D, Articulated dental casts that indicate analytic model planning. E, Panorex radiograph 1 day after surgery suggests a separate condylar component from the left ramus. F, Lateral and posteroanterior cephalometric radiographs taken 10 days after surgery indicate the same. G, Facial views before and 5 weeks after surgery. Persistent left side facial swelling is appreciated. H, Panorex and computed tomography scan views of the right ramus 5 weeks after surgery. I, Panorex and computed tomography scan views of the left ramus region 5 weeks after surgery confirm a bad split that demonstrates the expected anatomy. J, Left ramus computed tomography scan, left intraoral vestibular view, and sequestrectomy specimen with removed fixation screws. K, Frontal views in repose before and 11 weeks after surgery. L, Left facial oblique views before and then 11 weeks after surgery. M, Left profile views before and 11 weeks after surgery. N, Occlusal views before surgery and then 11 weeks postoperatively. O, Nine months after the completion of treatment, frontal facial and occlusal views demonstrate the results.

When the condyle separates as a third piece, intraoperative decisions will affect the postoperative recovery and occlusion (see Fig. 16-9). From the perspective of the occlusion, if the condyle or the medial pole remains with the distal segment, it will be as if no osteotomy on the ipsilateral side of the mandible was carried out. If no further action is taken, an intraoperative malocclusion should be recognized. To fully complete the ramus osteotomy, the surgeon must then separate (i.e., osteotomize) the condyle from the distal segment (i.e., create a third piece). The osteotomy should be carried out, with as much ramus left on the condylar segment (i.e., the third piece) as possible. Even when this type of bad split occurs, unless significant mandibular advancement is required for the correction of the jaw deformity, the successful healing of the segments will generally occur (see Figs. 16-9 and 16-10).

If the condyle separates (i.e., if a third piece is created) high up, the result is similar to that of a high condylar neck fracture. There will not be a stable posterior stop unless the surgeon is able to carry out plate and screw fixation of the condylar component (i.e., the third piece) to the rest of the proximal segment. This may not be practical, and it will depend on the morphology of the condylar piece. The incidence of postoperative malocclusion will also be dependent on the directional change planned for the distal mandible. If the mandible is to be advanced a significant amount, there is a greater probability that the minimally stabilized condylar segment (i.e., the third piece) will not heal in an ideal location relative to the residual proximal and distal segments. Alternatively, if the mandible is to remain relatively neutral or is set back, there is a higher probability that the condylar segment will heal to the residual proximal and distal segments in a favorable way (see Fig. 16-9). As long as healing is associated with adequate mobility (i.e., mouth opening), then any residual malocclusion can typically be managed 6 to 12 months later with redo SROs, if desired (see Chapter 35).

Unfortunately, there is no consensus with regard to what combination of factors predisposes an individual to a bad split. The literature shows the incidence of bad splits to vary from 1% to 23%. A buccal plate fracture of the proximal segment, a lingual plate fracture of the distal segment, and a coronoid process fracture of the proximal segment are the most commonly reported bad splits. Authors who consider these types of less than ideal osteotomies to be bad splits provide an explanation for the high incidence reported in some series. As previously stated, the majority of less than ideal separations (fractures) at the time of SSRO result in fixation challenges, most are not responsible for long-term negative sequelae.

The occurrence of a bad split is greatly reduced by keeping the medial osteotomy short (not to far back) and low (close to the occlusal surface of the mandibular molars) (Fig. 16-11). Using this technique a bad split as described should be a rare event (see Chapter 15).

Veras and colleagues evaluated risk factors and the functional and radiographic long-term results of a bad split.350 They also completed detailed temporomandibular joint examinations on patients with bad splits. Interestingly, they did not find the simultaneous extraction of a mandibular third molar in conjunction with an SSRO to be a risk factor for the development of a bad split. This is consistent with the research reported by Kriwalsky and colleagues,174 Precious and colleagues,268 and others (see discussion earlier in this chapter).

Facial sensibility of the area affected by either an SSRO or a chin osteotomy occurs through the mandibular nerve, which enters the mandibular foramen at the medial surface of the ramus.* This area is adjacent to and in front of the inferior alveolar artery and vein and just inferior to the occlusal plane of the mandibular molar teeth. The mandibular nerve becomes the IAN, and it runs with its vessels within the canal and supplies sensation to the three molars and the two premolar teeth. It then divides into two terminal branches. The incisive branch supplies sensation to the canine and incisor teeth, whereas the mental nerve exits from the foramen to supply sensibility to the chin, the lower lip mucosa and skin, and the adjacent gingiva. Damage to the IAN during either the ramus osteotomies or when completing an oblique osteotomy of the chin may occur. During SSRO of the mandible, the IAN can be damaged by a bur on a rotary drill, a saw blade on a reciprocating saw, an osteotome, or during the placement of plate and screw fixation (Fig. 16-12).

Posnick and colleagues completed a study to clarify normal chin, lower lip, and gingival sensibility in adolescents and then compared the normal values with sensibility measurements in three distinct groups of adolescents 1 year after these individuals had undergone mandibular osteotomy.261,263 One hundred fifteen subjects (230 mental nerves) were included in the study and divided into four groups. The first group included 67 individuals (Group I: n = 134 nerves; mean age, 18 years) who were undergoing orthodontic treatment; none had undergone orthognathic surgery. This group served as controls to determine the normal sensibility values of the chin, the lower lip, and the gingiva in adolescents. The remaining three groups were made up of adolescents who had previously undergone BSSRO of the mandible (Group II: n = 14 nerves; mean age, 19 years), osteoplastic genioplasty (Group III: n = 40 nerves; mean age, 19 years), or a combination of BSSRO and osteoplastic genioplasty (Group IV: n = 42 nerves; mean age, 19 years). Testing of Groups II, III, and IV was performed 1 year after the patients had undergone the indicated mandibular procedures. At the time of the 1-year postoperative examination, each patient was also asked to detail subjective impressions of current altered sensibility in the mandibular vestibular mucosa, the gingiva, the lower lip, and the chin region. The subjective questioning and objective testing were carried out by an occupational therapist who was trained in facial sensibility testing and familiar with the surgical procedures carried out. Fixed and reproducible coordinates in the area corresponding to the mental nerve were used for objective testing (Fig. 16-13). Three sensory modalities were tested at each coordinate for each involved nerve. Static two-point discrimination was measured with a MacKinnonDellon Disk-Criminator (Richardson Productions, Inc, Frankfort, Ill); vibratory thresholds were determined with a biothesiometer; and cutaneous pressure thresholds were measured with a set of SemmesWeinstein monofilaments. Sensibility values at 1 year after operation for Groups II, III, and IV were compared with the mean normal control values established for Group I. A subjective awareness of alterations in the sensibility of the chin, lip, or gingiva region 1 year after BSSRO was reported in 2 patients in Group II (29%), in 2 patients in Group III (10%), and in 14 patients in Group IV (67%). Interestingly, only 2 of these 18 patients considered the residual sensory loss problematic. The mean objective sensibility values of the three sensory modalities tested were highest among patients from Group IV. Significant differences were found only between the mean two-point discrimination of Group IV patients as compared with the control group in the chin skin area. Thus, 1 year after BSSRO, only 29% of patients had residual subjective awareness of sensory alteration along the distribution of the mental nerve. After an osseous genioplasty, there was only a 10% incidence of long-term subjective diminished sensibility. One year after a combination of BSSRO and osteoplastic genioplasty, 67% of patients experienced varying degrees of residual subjective loss of sensation in the chin and lip region.

Espelan and colleagues completed a 3-year postoperative survey of patients who had undergone SSRO (N = 583 subjects) and found that that 36.8% of the study patients reported impaired sensation over the long term.96A Westermark and colleagues completed a retrospective study of patients who had undergone SSRO and concluded that nearly 100% of the patients experienced impaired sensation and sensory function.358 This is also consistent with the findings of Essick and colleagues97 and Teerijoki-Oksa and colleagues.332,333 The exact reasons why, over time, most patients experience only a degree of simple loss of sensationwhereas some continue to experience active sensations that are not normally present and an even smaller percentage of those with active sensations subjectively describe them as uncomfortable or painful (dysesthesia)are not known. Zuniga and colleagues reported a 5% incidence of dysesthesia of the IAN after SSRO.380,381

Turvey reported a 5.5% incidence of IAN lacerations at the time of SSRO.343 Van Merkesteyn and colleagues documented a visible injury in the IAN at the time of SSRO in 7 out of 124 patients (6%).347 The term traumatic neuroma is used to describe the formation of a bulbous mass that develops at the end of a proximal nerve stump after partial or complete nerve transection. The lesion represents an exaggerated relative hyperplasia (i.e., healing) response to a nerve injury. Neuroma symptoms range from paresthesia to severe paroxysmal or persistent pain. Despite the incidence of partial or complete transection of the IAN at the time of SSRO, few cases of traumatic neuroma have been documented. This is likely because the healing transected nerve remains deep in the medullary cavity of the mandible. It is known that a healing nerve stump within bone is rarely painful. The few reported cases of neuroma after SSRO have confirmed the location to be within the soft tissues along the inferior border of the mandible.120,121

Essick and colleagues completed a clinical trial that determined that the magnitude and duration of the patient-reported burden of altered sensation after SSRO was lessened when facial sensory retraining exercises were performed in conjunction with standard mouth-opening exercises as compared with the group of patients who performed only mouth-opening exercises.97 The authors defined the term burden as the persons reporting of subjective impressions of numbness or unusual sensations (i.e., dysesthesia) in the face, the perioral region, and or oral region. One interpretation of the study findings is that patients who perform facial sensory retraining become more introspective with regard to their altered sensation, which leads to a greater acceptance of their sensory loss by 6 months after surgery. Consistent with this interpretation was the finding that sensory retrained patients initially viewed numbness and decreased sensitivity as more problematic early during recovery but as less problematic later during recovery than did the group of patients who did not undergo retraining.258 The retraining sessions were held at 1 week, 1 month, and 3 months after surgery. The levels of instruction for the sensory retraining were designed to increasingly challenge patients sensory discrimination abilities in a manner similar to that of the early and late phases of sensory retraining commonly used after injuries to the sensory nerves of the hand.120,121 Through sensory retraining, individuals learn to discriminate moving touch from non-moving touch; the orientation of moving touch; and the direction of moving touch (see Chapter 11). Poort and colleagues completed a literature review of methods that are used to test for sensory loss and recovery after IAN injury and recommended that clinicians and researchers use the following two measurement tools: 1) a light touch test with SemmesWienstein monofilaments for grading sensation; and 2) a visual analog scalebased questionnaire to evaluate the individuals subjective sensibility.261A If clinicians were to adopt consistent measuring techniques, improved communication with regard to sensory loss and level of recovery after interventions would likely follow.

A dilemma that surgeons continue to face is what to do in the operating room when the laceration of the IAN is witnessed. The question raised asks if there is any significant long-term advantage for the patient to undergo either primary or delayed micro repair of the lacerated IAN. Although the concept of the immediate repair of a witnessed IAN transection is appealing, the practicality of this maneuver and the patients long-term improved results (i.e., greater sensory return and decreased dysesthesia) have not been statistically confirmed. The increased operative time and the potential risks of losing focus on the primary orthognathic objectives must also be considered. Tay and colleagues reported four cases of immediate micro-neural repair of an IAN that was transected during SSRO.334 This represented 4 out of 260 (2%) SSROs completed at their center. One of the four patients who sustained IAN laceration was apparently lost to follow up. Interestingly, the location of IAN transection in the remaining three study patients was at the anterior and inferior aspect of the osteotomy along the buccal shelf between the first and second molars; this is a recognized danger zone for IAN transection during SSRO. When there is a moderate to severe degree of mandibular hypoplasia with the need for buccal shelf extension of the proximal segment to achieve successful approximation of the bone after advancement, this risk may increase. In the study by Tay and colleagues, the three study patients underwent immediate repair of the IAN (i.e., neurorrhaphy) by a trained microsurgeon and then received follow for 1 year.334 The microsurgeons technique included the complete surgical release of the nerve from the mandibular foramen to the mental foramen followed by approximation and repair with the use of 6-0 microfilament suture under microscope magnification. The increased time of the surgery was approximately 3 to 4 hours. Although the authors felt favorable regarding the outcomes of their patients, the level of sensory return that was documented was not proven to be significantly better than expected after the simple approximation of the nerve endings within the ramus of the mandible.

Note:

This author believes that a controlled study documenting significantly better sensory recovery after direct micro-neural repair that occurs via the simple approximation of the cut edges of the IAN in the setting of an SRO would be required to justify the added time and risk of the repair.

The incidence of injury to the lingual nerve during SSRO is not precisely known, but it is assumed to be rare.35,132,145,147,279,289291,327 Becelli and colleagues completed a retrospective analysis of complications after SSRO and found a 0.6% rate of lingual nerve dysfunction among 482 osteotomy patients during the first postoperative week. The authors documented complete resolution of this injury after 12 months of follow up in the study group. Interestingly, lingual nerve injury at the time of the removal of mandibular wisdom teeth as an isolated procedure is also estimated to be in the same range (i.e.,

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16: Complications Associated with Orthognathic Surgery …

Orthognathic surgery – Wikipedia

Orthognathic surgery [1] 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.[2] 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.[3][4][5] Orthognathic surgery can be used to correct;

Like any other surgery, there can be complications such as bleeding, swelling, infection, nausea and vomiting.[7] There could also be some numbness in the face due to nerve damage. The numbness may be either temporary, or, more rarely, permanent.[8] In general, complications of this surgery occur infrequently.[9]

If the surgery involved the upper jaw, then the surgery could have an effect on the shape of the patient’s nose. This can be minimised by careful planning and accurate execution of the surgical plan. Sometimes, this is considered part of the benefit. Possible damage and scarring to the paranasal maxillary sinuses (located under the eyes) is a side effect to any orthognathic surgery.

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,[10][11] which is useful both for planning and for explaining the surgery to the patient and the patient’s family.[12] 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.[13] Orthognathic surgery is also available as a very successful treatment (90100%) for obstructive sleep apnea.[14] 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.

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Orthognathic surgery – Wikipedia

Best Orthognathic Surgery, Jaw Correction Surgery, India …

Orthognathic surgery is definitely for you have the jaw surgery and start enjoying its benefits.

Orthognathic surgery is an operation that will reposition the lower, upper or both jaws, for individuals with an abnormally positioned jaw in relation to the base of the skull or individuals who have large discrepancy between the sizes of the jaws in relation to each other. Orthognatic surgery can be used to change your facial shape completely.

The Jaw surgery is performed only after a detailed initial consultation. At the beginning of the treatment, the teeth are first aligned, at the same time the useless teeth such as the wisdom teeth are removed. When the orthognathic treatment starts, it usually takes about 18 to 24 months for the teeth to straighten with the help of braces. When the teeth are all set up, its now the right time to perform orthognathic surgery that will be done on one of the jaws or both. Then it will be followed by the final orthodontic treatment which lasts for approximately 6 months.

After all this is completed, the patient can now enjoy the benefit of having pleasing facial features and a stunning smile.

It is normal that a patient who goes through the jaw reshaping or jaw correction surgery will feel pain or have some some discomfort after the orthognathic surgery, although the pain varies from one patient to another, depending on their pain tolerance level. So make sure that you take your medications as directed.

You will be able to shower on the second day after the jaw surgery, however, you need to avoid prolonged and hot shower, which may lead to bleeding of your lower jaw, if the surgery is performed there.

You must avoid exercises, any activity such as lifting or activities that may raise your blood pressure or pulse for at least a month following the orthognathic surgery. Any activity that may increase the blood pressure may result in bleeding since the blood vessels are still healing from the surgery. Gentle exercises can be done after 2 weeks, but dont do any cardio for 4 to 6 weeks after the jaw reshaping. Dont drive a vehicle for the next 48 hours.

It is common to have minor bleeding from the surgical area in the mouth or from the nose. The bleeding or oozing will usually last for 7 to 10 days after the jaw reshaping. However, when the bleeding activity is excessive, make sure to call your doctor.

Swelling is generally expected after the orthognathic surgery, but this also varies from patient to patient. A large degree of swelling may be anticipated over your cheek area as well as down, over your neck. Maximum swelling will occur at approximately 4 days post surgery, but will slowly subside after approximately 2 weeks. For the next 2 to 3 months, a little swelling about 10 20 % is anticipated. For the first 3 to 5 days following the jaw surgery, you can place ice on your face, when you are awake.

On the 4th day, it is recommended to have a warm water bottle aligned to your face, to help reduce the swelling.

For the first 24 hours, nausea and vomiting are common. If vomiting and nausea persist, make sure to let your doctor know.

Use the Pain medication, mouth rinse, and antibiotic prescribed by your doctor. Use them as instructed on the bottle.

Orthognathic surgerys best patients are those from ages 18 to 45. Jaw surgery is best performed after the jaw stops growing, which is normally at the age of 18 years. Jaw correction surgery is rarely used on children aged 18 and below. The patients under 18 have a treatment limited to the growth modification of the jaws, and orthodontics; however, if the orthodontics wasnt successful or ineffective, the parents of the patient and as well as the patient must provide their consent, before setting up the patient for an orthognathic surgery.

Mostly, patients lose between 5 to 10 pounds in the first month of their recovery, as chewing will be difficult and you are typically put on a liquid and a semi-solid diet.

Achieving perfection in anything requires time, effort and expenditure. In the case of our face and bodies, however, effort is not entirely sufficient to achieve what we have always desired. IN such situations, cosmetic surgery can be a worthwhile investment and allow us to attain the looks we have always wanted. Orthognathic surgery is one such corrective procedure that can sculpt your jaws and give you the cheekbones of your dreams.

Any cosmetic procedure is a significant investment. Having decided to undergo orthognathic surgery, naturally, you would wonder, How much is the cost of the orthognathic surgery? The costs associated with the surgery vary from patient to patient, depending upon the extent of reconstruction. In India, cosmetic surgery can be availed at a fraction of the costs of costs in UK, USA and Singapore without any compromise on the quality of care.

We, at The Esthetic Clinic, are committed to providing you the very best quality of care during the course of your cosmetic surgery. Dr. Debraj Shome, our leading surgeon is a well know oculoplastic surgeon in Mumbai, India. We have the latest surgical equipment and highly-trained and specialised staff who use the latest techniques to give you your dream look.

The Esthetic Clinic is a medical centre specialised to perform skin-care treatments and cosmetic surgery. Our medical head, Dr. Debraj Shome, is a highly experienced facial cosmetic surgeon who has extensive experience conducting a wide range of cosmetic procedures. You can trust The Esthetic Clinic to help you achieve the look you have look you have always wanted.

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Dr. Debraj Shome Founder, The Esthetic Clinic, is a top facial plastic surgeon. Dr. Shome is currently a Consultant at the best Mumbai hospitals like Saifee Hospital, Breach Candy Hospital, Holy Family Hospital & Nova Specialty Hospital in Mumbai, India. He has 40+ research papers in international journals, numerous presentations at conferences & many awards such as Best Plastic Surgeon in Mumbai, Top 10 Cosmetic Surgeon in India, Best Oculoplastic Surgeon India, etc. A celebrity plastic surgeon, Dr. Shome believes plastic, reconstructive & cosmetic face surgery can allow you to lead a more fulfilled life Read more

E: debrajshome@gmail.com |M: +91 9004671379

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Best Orthognathic Surgery, Jaw Correction Surgery, India …