Orthognathic surgery
Orthognathic surgery | |
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ICD-9-CM | 76.6 |
Orthognathic surgery (
The origins of orthognathic surgery belong in oral surgery, and the basic operations related to the surgical removal of impacted or displaced teeth – especially where indicated by orthodontics to enhance dental treatments of malocclusion and dental crowding. One of the first published cases of orthognathic surgery was the one from Dr. Simon P. Hullihen in 1849.
Originally coined by Harold Hargis, it was more widely popularised first in Germany and then most famously by Hugo Obwegeser who developed the bilateral sagittal split osteotomy (BSSO). This surgery is also used to treat congenital conditions such as
The "jaw osteotomy", either to the upper jaw or lower jaw (and usually both) allows (typically) an oral and maxillofacial surgeon to surgically align an arch of teeth, or the segment of a dental arch with its associated jawbone, relative to other segments of the dental arches. Working with orthodontists, the coordination of dental arches has primarily been directed to create a working occlusion. As such, orthognathic surgery is seen a secondary procedure supporting a more fundamental orthodontic objective.
It is only recently, and especially with the evolution of oral and maxillofacial surgery in establishing itself as a primary medical specialty – as opposed to its long term status as a dental speciality – that orthognathic surgery has increasingly emerged as a primary treatment for obstructive sleep apnoea, as well as for primary facial proportionality or symmetry correction.
The primary use of surgery to correct jaw disproportion or malocclusion is rare in most countries due to private health insurance and public hospital funding and health access issues. A small number of mostly heavily socialist funded countries report that jaw correction procedures occur in some form or other in about 5% of a general population, but this figure would be at the extreme end of service
Increasingly, as people are more able to self-fund surgery, 3D facial diagnostic and design systems have emerged, as well as new operations that enable for a broad range of jaw correction procedures that have become readily accessible; in particularly in private maxillofacial surgical practice. These procedures include IMDO, SARME, GenioPaully, custom BIMAX, and custom PEEK procedures. These procedures are replacing the traditional role of certain orthognathic surgery operations that have for decades served wholly and primarily orthodontic or dental purposes.[6] Another development in the field is the new index called the index of orthognathic functional treatment need (IOFTN) that detects patients with the greatest need for orthognathic surgery as a part of their comprehensive treatment.[7] IOFTN has been validated internationally and detected over 90% of patients with greatest need for orthognathic surgery.[8]
Medical uses
It is estimated that nearly 5% of the UK or US population present with dentofacial deformities that are not amenable to orthodontic treatment requiring orthognathic surgery as a part of their definitive treatment.[9][4][5] Orthognathic surgery can be used to correct:
- Gross jaw discrepancies (anteroposterior, vertical, or transverse discrepancies)[10]
- Skeletofacial discrepancies associated with documented sleep apnea, airway defects, and soft tissue discrepancies
- Skeletofacial discrepancies associated with documented temporomandibular joint pathology
A disproportionately grown upper or lower jaw causes dentofacial deformities. Chewing becomes problematic, and may also cause pain due to straining of the jaw muscle and bone. Deformities range from
- Cleft lip and palate
Orthognathic surgery is a well established and widely used treatment option for insufficient growth of the
Risks
Although infrequent, there can be complications such as bleeding, swelling, infection, nausea and vomiting.[21] Infection rates of up to 7% are reported after orthognathic surgery; antibiotic prophylaxis reduces the risk of surgical site infections when the antibiotics are given during surgery and continued for longer than a day after the operation.[22]
There can also be some post operative facial numbness due to nerve damage.[23] Diagnostics for nerve damage consist of: brush-stroke directional discrimination (BSD), touch detection threshold (TD), warm/cold (W/C) and sharp/blunt discrimination (S/B), electrophysiological tests (mental nerve blink reflex (BR), nerve conduction study (NCS), and cold (CDT) and warm (WDT) detection thresholds.[24] The inferior alveolar nerve, which is a branch of the mandibular nerve, must be identified during surgery and worked around carefully in order to minimize nerve damage. The numbness may be either temporary, or more rarely, permanent.[25] Recovery from the nerve damage typically occurs within three months after repair.
Surgery
Orthognathic surgery is performed by maxillofacial or an
Planning
Planning for the surgery usually involves input from a multidisciplinary team, including 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. 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. There is also advanced software that can predict the shape of the patient's face after surgery,[26][27][28][29][30] which is useful for the planning and also explaining the surgery to the patient and the patient's family.[31] Great care needs to be taken during the planning phase to maximize airway patency.
Orthodontics are a critical component of orthognathic surgery. Traditionally the presurgical orthodontic phase can take as long as one year and undertaken with conventional metal braces.[32] However, these days new approaches and paradigms exist including surgery-first [33] And using clear aligner orthodontia (like Invisalign)[34][35]
Sagittal split osteotomy
This procedure is used to correct
Genioplasty osteotomy (intra-oral)
This procedure is used for the advancement (movement forward) or retraction (movement backwards) of the chin. First, incisions are made from the
GenioPaully
This is a modified box osteotomy of the chin, designed to deliberately grab the paired
Rapid palatal expansion osteotomy
When a patient has a constricted (oval shape)
Post operation
After orthognathic surgery, patients are often required to adhere to an all-liquid diet for a time. Weight loss due to lack of appetite and the liquid diet is common. 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.
Recovery
All dentofacial osteotomies require an initial healing time of 2–6 weeks with secondary healing (complete bony union and bone remodeling) taking an additional 2–4 months. The jaw is sometimes immobilized (movement restricted by wires or elastics) for approximately 1–4 weeks. However, the jaw will still require two to three months for proper healing. Lastly, if screws were inserted in the jaw, bone will typically grow over them during the two to three month healing period. Patients also may not drive or operate vehicles or large machinery during the consumption of painkillers, which are typically taken for six to eight days after the surgery, depending on the pain experienced. Immediately after surgery, patients must adhere to certain infection preventing instructions such as daily cleaning, and the consumption of
History
Prior to 1991, some patients undergoing a dentofacial osteotomy still had
Advances in the surgical techniques allow surgeons to perform the surgery under
See also
References
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- ^ Mandible (Lower Jaw) Osteotomy. 2007. British Association of Oral and Maxillofacial Surgeon (BAOMS). 29 February 2009 http://www.baoms.org.uk
- ^ Puricelli, Edela. "A new technique for mandibular osteotomy." Head & Face Medicine 3.15 (2007). Head & Face Medicine. 13 March 2007. BioMed Central Ltd. 27 February 2009 http://www.head-face-med.com
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