ORTHOGNATHIC SURGERY

DEPARTMENT OF ORTHOGNATHIC SURGERY

The Orthognathic Surgery Department is dedicated to the diagnosis and surgical treatment of changes in adult facial bone development.


Orthognathic surgery is an intervention that corrects dentofacial asymmetries in order to achieve a perfect balance of the face and teeth. Dentofacial dysmorphias are quite common in the general population.

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THE ORTHOGNATHIC SURGERY

Orthognathic surgery is an intervention that corrects dentofacial asymmetries in order to achieve a perfect balance of the face and teeth.

After a variable period of orthodontic treatment, the intervention is performed on the jaws to achieve a perfect balance between all the patient's facial features, correct occlusion and improve breathing (boosting greater air passage through the upper airway).


As we change the position of the jaws forward, backward, upward or downward, the soft facial tissues also move with them, that is, the chin, lips, cheeks and the tip of the nose, the height of the face changes accordingly. Thus, once the jaw is placed in a correct position, the facial profile becomes correct and produces harmonious new facial features.


Orthognathic surgery is closely related to orthodontics. Normally, treatment begins with wisdom tooth extraction, followed by orthodontic treatment prior to surgery that lasts between 1 and 2 years, in collaboration with the orthodontist. This time may be shorter, depending on the case. Therefore, the correction of dentomaxillofacial deformities always involves teamwork between the orthodontist and the surgeon.

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DENTOFACIAL DEFORMITY

Dentofacial dysmorphias are quite common in the general population. Usually, people find that they have difficulty in chewing because their teeth do not fit well or because they notice a change in the size of their chin which negatively influences their self-esteem. The problems where this procedure is indicated are:



  • Mandibular prognathism or "big chin"
  • Retrognathism or "small chin"
  • Gingival smile or "gummy smile"
  • Open bite or "front upper and lower teeth that slant outwards"
  • Cross bites and facial asymmetry or "crooked or deviated face"

MANDIBULAR PROGNATHISM

MANDIBULAR RETROGNATHISM

GINGIVAL SMILE

OPEN BITE

CROSSBITE

These bone changes result in an incorrect position of the teeth, with a negative impact on facial harmony/aesthetics. These can be treated in isolation or associating various aspects, creating an individualized treatment plan to obtain the best functional and aesthetic result in each case of orthognathic surgery.


Treatment with orthognathic surgery is a procedure that always includes associated orthodontic treatment before and after surgery. After orthognathic surgery, intensive rehabilitation treatment is always necessary.


Changes in the length, width or height of the jaw result in difficulty in accommodating the teeth as well as changes in the relationship between the upper and lower teeth. The teeth try to adapt to this lack or excess of bone, adopting positions different from those they would have if the structure were correct. Excessive showing of the gums when smiling, inability to completely bring the lips together effortlessly, not showing the upper teeth when smiling, jaw back, jaw forward, crooked teeth in the jaw, facial asymmetries, chin back, chin forward, are some of the main complaints of our patients. These problems, being of the jaws and teeth, must be treated together with Orthodontics (to decompensate the adopted position) and surgery (to put the jaws in the correct position), otherwise this could give to unsatisfactory final results, indefinite and recurrent orthodontic treatments, with patients often experiencing asymmetries on the face, for example, a deviated chin with important aesthetic implications.

WHAT ARE THE MOST COMMON FACIAL CHANGES AND MALOCCLUSIONS?

  • > ANSWER

    A discrepancy between the position of the maxillary bone and the mandible is referred to as skeletal malocclusion, which can be of two types in relation to the antero-posterior plane:


    CLASS 2: also known as mandibular retrognathism and/or maxillary prognathism, which occurs when the jaw is advanced in relation to the mandible.


    CLASS 3: also known as mandibular prognathism and/or maxillary retrognathism which occurs when the mandible is advanced in relation to the maxilla.


    Other common malocclusion problems are narrow palate, open bite, cross bite, edge to edge bite, overbite or crowding.

    In addition to malocclusions, poor placement of the jaw bones can also cause other malformations, such as:


    Facial asymmetry: when one side, or part of one side of the face, is unbalanced with the other

    Gingival smile: when excessive gingival tissue (or gum) is shown when smiling

WHERE SHOULD A PATIENT GO TO RESOLVE THE PROBLEMS REFERRED TO ABOVE?

  • > ANSWER

    Patients who identify these problems can go to a centre specializing in orthognathic surgery and/or to their orthodontist for an initial consultation. Once these professionals assess the patients’ complaints and expectations, dental situation, occlusion and jaw size and facial harmony, they can decide whether orthodontic treatment is sufficient or whether orthognathic surgery is necessary.

WHY IS IT NECESSARY TO TREAT MALOCCLUSION?

  • > ANSWER

    In the case of a malocclusion, the tissues that surround the tooth are injured when chewing food, therefore, inflammation occurs and the bone begins to thin. As the bones become thin, the mobility of the teeth increases, spaces may appear between the teeth. On the other hand, if the teeth are in the wrong position, dental plaque begins to accumulate quickly and causes inflammation of the tissues surrounding the tooth, then caries damage your teeth.


    In some cases, malocclusion can create lesions in the temporomandibular joint due to overload.


    Finally, the patient's expectations are fundamental in wanting to have a charming smile and an aesthetic appearance.

WHEN CAN ORTHODONTIC TREATMENT BEGIN?

  • > ANSWER

    It is extremely important to note the incorrect growth of the jaws in children from 9 to 13 years of age, as it is precisely at this age that it is possible to correct the situation through functional orthodontic appliances. The treatment lasts approximately a year and half.


    In the case of patients over 13 years of age, if the maxillary alteration is already established, orthodontic treatment can be started, with the duration of the treatment being 1 to 2 years.


    There are no age-related limitations for orthodontic treatment; however, orthodontic treatment for the elderly can be more complicated and take longer. Over the years, bone tissue reabsorption occurs, which makes orthodontic management more complicated.

WHEN IS SURGICAL TREATMENT PERFORMED?

  • > ANSWER

    Orthognathic surgery can be performed on patients over 18 years old. The complete orthodontics-surgery-orthodontics treatment takes 2 to 3 years, in collaboration with the orthodontist.

HOW WILL MY FIRST ORTHOGNATHIC SURGERY APPOINTMENT BE?

  • > ANSWER

    You will be received by the surgeon for a discussion of all the necessary information, such as: complaints and tests, problems with dental occlusion and if you suffer or have suffered from any disease or allergy. All this information will be collected together with the facial and dental analysis for a complete record of the clinical case. This case file will be given to you so that you can pass it on to your orthodontist, in order to develop the most appropriate treatment plan. If you do not have a referral orthodontist, the information will be provided for the most appropriate choice.


    If you already have an orthodontist, please bring a panoramic radiography of the oral cavity (orthopantomography), a lateral radiography of the head and dental models made of plaster. If you do not have these items, plans will be made to obtain them.


    For registration and clinical analysis, photographs of the front and profile will be taken.


    During the presentation of the treatment plan, aspects such as treatment details, approximate duration, risks and possible complications will be discussed.

WHAT HAPPENS DURING PRE-SURGICAL ORTHODONTIC TREATMENT?

  • > ANSWER

    All wisdom teeth must be removed before orthodontic treatment begins. The extraction can be performed before or during orthodontic treatment, but in all cases, at least 6 months before orthognathic surgery.


    It may be that the extraction of two or four healthy teeth is necessary due to a substantial mismatch between the sizes of dental arches or crowded teeth.


    The objective of preoperative orthodontics is to eliminate any existing dental compensation and provide the surgeon with a stable and appropriate structure between the upper and lower arches, aligning the teeth, so that the surgeon can carry out the planned skeletal movements, with the objective usually being achieved within 12-18 months. Postoperative orthodontic treatment is essential to achieve proper occlusion by the end of treatment.

    Once the teeth are in the ideal position to operate, the preoperative study includes a 3D CAT scan, new dental records and photographs, which will be studied by the surgeon in order to plan the case perfectly with millimetre precision, supported by 3D digital programming methods.


    Virtual planning in orthognathic surgery was introduced in the last decade and offers surgeons the best current diagnostic and planning tool. Using Cone Beam Tomography, scanning of models and 3D planning software, we can plan, simulate and perform the surgery with millimetre precision. This enables the surgeon to exchange information with the orthodontist, simulate and evaluate the surgical possibilities with the patient even before performing the surgery, ensuring greater predictability of the case and greater patient satisfaction. In addition to assisting in planning, the 3D software ensures greater information and accuracy during the execution of the surgery itself, reducing time and surgical trauma during the procedure.


    One week before the operation, muscle assessment of the cervicofacial and swallowing muscles will be performed to re-evaluate patient functionally in order to compare it with the therapies applied in the postoperative period. Preoperative medical exam requests will be delivered and evaluated by the surgeon and the anaesthetist.

WHAT ARE THE NEW ADVANCES IN ORTHOGNATHIC SURGERY?

  • > ANSWER

    • The new advances are in the planning of surgery using 3D technology, as mentioned in the previous point, achieving a greater forecast and surgical precision.
    • When performing surgery: Ultrasonic surgery or computer-assisted piezoelectric surgery assisted by piezoelectric, bone incisions (osteotomy) by ultrasound, not reaching the soft tissues and being much more precise and less traumatic for the hard tissues.
    • In the postoperative period, the Hiloterm® facial cooling mask works with anatomical accessories for all parts of the body, being indicated as the most effective and modern method in post-surgical trauma recovery using cryotherapy/effective thermotherapy for alleviating pain and swelling by keeping the face at a continuous and controlled temperature of 15ºC.

WHAT SHOULD I KNOW BEFORE SURGERY?

  • > ANSWER

    • Orthognathic surgery is a planned procedure and so is not performed if the patient has an active infection, in which case it will be postponed until the patient's clinical situation is suitable.
    • The stomach must be empty before surgery.
    • Eating and drinking in the morning before surgery is strictly prohibited. This is an extremely important rule - if the stomach contents enter the airways, it can lead to a fatal outcome.
    • The operation is always performed under general anaesthesia.

WHAT ARE THE RULES FOR FOOD AND HYGIENE AFTER THE SURGERY?

  • > ANSWER

    During the first weeks after surgery, the patient’s diet should be based on fluids, after which the surgeon will guide the progressive introduction of food. Oral hygiene is fundamental at this stage and should be performed with a soft-tipped brush several times a day, together with oral rinses and the application of oral antiseptic gel.

DO I HAVE TO USE ELASTICS ON MY TEETH AFTER SURGERY?

  • > ANSWER

    The correct placement of the rubber bands is crucial for a correct result. The bands are placed immediately following the intervention to help teeth stability. These must be removed during meals and put back after oral hygiene and must be completely changed once a day. The surgeon will guide your placement during the first few weeks after orthognathic surgery. The times without elastic support will be progressively longer and the elastics will be of lesser strength.


    The surgeon must accompany the patient at least until the orthodontic appliance is removed.

TYPES OF ORTHOGNATHIC SURGERY

MAXILLA SURGERY

Orthognathic surgery on the jaw places the jaw in the correct position to achieve facial harmony, and most importantly, a recovery of the functionality of this bone, which is essential to chewing, breathing and speaking.


This procedure is performed to correct various facial deformities, such as mandibular prognathism or Class 3, open bite or gingival smile.


Orthognathic surgery of the jaw consists of an incision in the jaw bone called Le Fort I osteotomy, which enables the advance, retrusion, stretching, shortening or rotation of the jaw bone. Once in the desired position, the jaw is fixed with titanium plates and screws, a completely biocompatible material.

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JAW SURGERY

Due to the risks involved in mandibular reduction surgery (narrowing of the airways), the most commonly performed orthognathic surgery in the jaw is mandibular advancement surgery. This procedure is necessary when people have a small jaw that is retracted from the maxilla, a condition known as retrognathia or class II. We reserve mandibular setback in cases of severe mandibular prognathism in classes III, usually in combination with advancing maxillary surgery, in the context of bimaxillary surgery.


This type of malformation especially affects the harmony of the lower face and causes various functional problems, such as sleep apnoea.


Mandibular advancement surgery consists of cutting each side of the mandible bone, known as bilateral sagittal osteotomy, advancing the bone and fixing the bone in the new position using titanium plates, a completely biocompatible material.

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MAXILLOMANDIBULAR OR BIMAXILLARY SURGERY

In most patients with dentofacial changes, it is necessary to reposition the maxilla and mandible to achieve correct occlusion and facial harmony. This procedure is known as maxillomandibular surgery or bimaxillary orthognathic surgery.


Bimaxillary orthognathic surgery is used to treat the following Class 2 and Class 3 malformations, facial asymmetry, or open bite, among others, when monomaxillary surgery is not sufficient to remedy the patient's problems.


Mentoplasty or chin surgery, to achieve an excellent result, where indicated, this must be performed at the same time as the orthognathic surgery.


The surgery is performed by incisions inside the mouth, where the wounds take to ten days to heal, the stitches are resorbable and on average the mandible is consolidated in 2 months, and the maxilla is consolidated in 4 months. The average stay in the clinic is one day. Facial cooling equipment will be placed to minimize postoperative oedema and lymphatic drainage will also be performed on the second postoperative day.


During the 3 months after surgery, there will be various physiotherapy and speech therapy sessions, together with the surgeon's supervision, for an excellent functional recovery.

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MENTOPLASTY


Mentoplasty is an outpatient chin surgery, very safe and with great results. In some parts of the world, this surgery even supplants other types of cosmetic surgery, such as liposculpture or mammoplasty.


In addition to being one of the most important features defining our face, the chin is also a facial gender sign, which leads to increasingly more people to use chin repair to increase, decrease or symmetrize their face.


This surgery is performed through a small incision inside the mouth (leaving no scar), where we increase or decrease the chin bone, and can also use a custom prosthesis to achieve the desired facial aesthetic outcome.


These types of techniques leave a permanent result in the patient, and chin treatments include other techniques such as the infiltration of hyaluronic acid or fat collected by liposuction of the thighs or belly. In recent times, the modelling of the chin contour or contouring has proved to be a high-performance technique in facial aesthetics.


One of the great advantages of mentoplasty is its light postoperative effect in relation to other aesthetic surgeries and the evidence of the final result in a short period of time.

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SLEEP APNOEA AND HOW TO SOLVE IT WITH ORTHOGNATHIC SURGERY

IPFACE TEAM 

ASSIGNED TO THE DEPARTMENT

COORDENADOR DE DEPARTAMENTO

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