Cosmetic Jaw Surgery

Orthognathic (Jaw) Surgery

This implies surgery to straighten the jaws. Cases are planned with an Orthodontist who treats the frequent malocclusion present in such a way that the dental occlusion will be correct following the surgical procedure.

Presurgical orthodontic treatment often involves fixed brace treatment lasting

18-24 months, and is essential for the stability of the result.



Invisible Orthodontics

At NCAFOS Clinics we shall have access to “invisible” brace treatment which is suitable for some patients. This is carried out using fix braces placed on the tongue (lingual) sides of the teeth or by using a series of transparent dental splints (Invisalign®) http://www.invisalign.com/GB/index.html which fit over the teeth like a boxers gum shield.

At the end of an average of 12 - 18 months of orthodontic treatment, the surgical plan is confirmed with computer analysis of skull x-rays. Digital photographs are manipulated on screen (Photomorphanalysis™) to predict the cosmetic appearance following surgery to one or both jaws (osteotomy).

Surgical (Instant) Orthodontics

An osteotomy is a controlled surgical fracture of bone, and is usually carried out with saws and instruments which can split the bone along its natural “grain”. Combined with Invisible Orthodontic treatment, and planned using Engineering Assisted Surgery techniques and customised jigs, precision osteotomy bone cuts between the tooth roots may be used to mobilise teeth so that they may be orthodontically moved into the correct position using treatment lasting a few days or weeks – instead of months or years. This concept is a major breakthrough in the treatment of misaligned teeth.



Computer Simulated Segmental Osteotomy
illustrating the mobilisation of two lower teeth



Jaw Surgery (Osteotomy) Procedures

a) Mandibular Sagittal Split Osteotomy

The back of the lower jaw is split bilaterally under general anaesthetic in the region of the wisdom teeth, which are generally removed in a separate operation at least 6 months prior to corrective surgery.

The procedure is carried out in about 1.5 hours and permits the lower jaw to be advanced or pushed back with adequate bone contact for healing.

The bone is fixed in its new position by screws which are inserted through tiny external skin incisions which are located at the angle of the jaw. These heal with minimal external scarring.



Mandibular Sagittal Split Osteotomy
and Genioplasty (Chin Surgery)

The mandible has been pushed backwards and surgery has been carried out to the chin (Genioplasty)Sensory Nerves to the lower lip pass through the jaw and are coloured blue


Whilst day case treatment is practiced in the USA, it is common practice in the UK to spend one night as an in-patient.

Some adjustment to the position of the dental occlusion (bite) is not uncommon following surgery. This is achieved by joining the upper and lower jaws together with elastic band traction for a week or two.

Facial swelling is variable and is controlled with intravenous steroid injections over the first 24 hours. Patients require a liquidised diet if the jaws are held together with elastics - or soft diet for the first two weeks, after which time more solid food can be introduced.

Specific Complications:



The Mandibular Sagittal Split Osteotomy

The sensory nerves to the lower lip are coloured blue.

Screw fixation is demonstrated on one side. Screws are placed above and below the nerve



Sensory Nerves

The sensory nerve to the lower lip (inferior dental nerve) runs in the lower jaw in the region of the osteotomy bone cuts. Immediately following the surgery all patients should expect numbness of the lower lip, which improves over a period of months. A degree of permanent altered sensation remains in about 30% of patients and affects one or both sides of the lower lip. This may range from complete numbness as experienced with a dental injection to mild tingling. Male patients may not feel if they cut themselves whilst shaving. The majority of patients, who experience permanent altered sensation to the lower lip, find that it is of little significance, and have no regrets about surgery. Reports of psychological problems and or depression related to sexual activity and altered/reduced pleasure from kissing in particular have been reported but are rare. Similarly the condition of painful numbness (dysthesia) has been reported but is rare. Repair of an injured inferior dental nerve is possible but technically difficult. Such a repair is not guaranteed to restore normal sensation.

The sensory nerve to the tongue lies close to the osteotomy cuts in the soft tissue and is retracted away from the operation site. Altered sensation associated with this traction is rare and usually temporary.

Motor Nerves

Motor nerves are nerve that make muscles contract. Injury to the facial nerve supplying movement for the lower lip has been reported as a result of insertion of screws through the small external skin incisions. This may produce some weakness of the lower lip - more noticeable on smiling and may be permanent. This is a very rare complication.



Relapse

Long term complications include relapse, which may occur if the jaw is advanced or if the jaw is retracted. The cause is controversial. It is thought to be related to continued growth in some patients - seen when the jaw is pushed back, and muscle pull - when the jaw is advanced large distances to accentuate a small chin. It is therefore important to carry out such operations when growth has ceased. Muscles inserted into the chin may be divided in the floor of mouth in cases of large jaw advancement - circa 1cm (myotomy). The majority of cases of relapse are noticed by slight changes in the dental occlusion only noticed by the clinician. It is very rare for relapse to adversely affect the cosmetic improvement achieved.



b) Chin Surgery – Genioplasty

The position of the chin is critical and influences the facial height, facial centre-lines and cosmetic appearance of the nose. Patients seeking rhinoplasty may discover that their perceived cosmetic problem lies elsewhere – the chin. The effect of both rhinoplasty and/or genioplasty may be demonstrated to the patient on screen during the initial consultation using computer technology.

The chin may be moved backward / forwards / upwards / downwards with an intraoral incision behind the lower lip, to correct an abnormal position. It may also be moved to the facial centre line in cases of facial asymmetry.

Post surgery a pressure dressing is applied to the chin for about 72 hours. This reduces bruising which may sometimes travel down the tissue planes into the neck and even onto the chest. Such bruising is not necessarily related to surgical technique and may be related to a tendency for blood vessels to ooze following surgery.

c) Liposuction and Liposculpture

A “double chin” is a common feature and may be treated alone or in combination with the chin and lower jaw. Liposuction may be carried out through a tiny skin incision under the chin. The removal of fatty tissue is carried out using suction (Liposuction) which may be carried out laterally in the neck to provide a better jaw line and for the treatment of jowling (Liposculpture), through additional skin incisions near the angle of the jaw.

The effects pf liposuction / liposculpture may be simulated on screen with computer technology at the time of initial consultation.

d) Upper Jaw - Maxilla

Maxillary osteotomy surgery may be advised when an abnormally positioned jaw is giving rise to cosmetic problems. The jaw can be moved upwards / downwards / forwards and rarely backwards.

The critical aspect of where to place the maxilla in the anteroposterior plane is determined by computer analysis of skull x-rays and computer simulation using digital photography (photomorphanalysis™). This illustrates the movement and its permits effect on other structures to be calculated e.g. the nose.

The position of the maxilla in the vertical plane is determined by the amount of upper incisor tooth visible below the upper lip at rest and when smiling.

Rotation of the maxilla may be required on occasion to centralise the position of the front teeth. This has a temporary effect on the central position of the nose, which initially looks “off centre” – this usually corrects itself over a 3 month period.

Surgery to the maxilla is carried out at three levels named after a French Surgeon René Le Fort.



Le Fort I Osteotomy
Sensory nerves to the upper lip and cheeks are coloured blue


The Le Fort I osteotomy involves separating the maxilla and the palate from the skull above the roots of the upper teeth through an incision inside the upper lip. The maxilla is fixed in its new position with titanium screws and plates. Surgery time is around three hours. The operation is frequently carried out with the mandibular Sagittal split osteotomy when it is termed a Bimaxillary Osteotomy.

Bimaxillary osteotomies take around five hours to complete and may be carried out in conjunction with chin surgery and liposuction/liposculpture. Blood transfusion is required. On occasions bone grafting is required in the Le Fort I osteotomy to ensure bone healing and union across the bone cuts. The graft is frequently harvested from the hip. Bone graft material may be harvested from the chin or lower jaw in bimaxillary cases – leaving the hip intact.

Cosmetic improvement is startling for those individuals requiring these procedures, and with proper planning it is unusual for patients not to be delighted with outcome.





Le Fort II Osteotomy
Sensory nerves to the cheeks and forehead are coloured blue


The Le Fort II Osteotomy is an uncommon procedure used when there has been a problem with growth in the centre of the face and the upper jaw and nose requires movement together. This is a major surgical operation, and involves incisions in the mouth, cosmetic incisions behind the lower eyelids (transconjunctival) or through the skin below the lower eyelids (blepharoplasty). The nose is approached with a cosmetic incision over the top of the head from ear to ear (bicoronal approach) and the scalp is raised forwards to get access to the nasal bones. Sensory nerves to the forehead require to be freed from bony canals (illustrated). Hip grafts (illustrated in red) are needed to fill in any gaps after the upper jaw and nose have been moved (usually forwards).

Surgery time is around 8 hours; blood transfusions are required and the patient is nursed in a high dependency unit overnight following the operation. Suction drains are placed in the scalp to reduce bruising. Patients may have considerable facial swelling and black eyes following this procedure. Aesthetic improvement is startling for those patients requiring this type of surgery.



Le Fort III Osteotomy


The Le Fort III Osteotomy is used to correct generalised growth failure of the midface involving the upper jaw nose and cheek bones (zygomas). The surgical approach and post operative management is similar as for the Le Fort II procedure.

Brow lift procedures may be carried out at the same time as Le Fort II and Le Fort III osteotomies.



Le Fort III Osteotomy
lateral view


The lateral view of the Le Fort III osteotomy illustrates the use of an additional plate and bone grafting in the region of the Zygomatic arch.