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 speech and language therapist. 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, which is useful both for planning and for explaining the surgery to the patient and the patient’s family. 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. Orthognathic surgery is also available as a very successful treatment (90–100%) for obstructive sleep apnea. Great care needs to be taken during the planning phase to maximize airway patency.Procedure
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 amaxillomandibular 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.
Risks from any anesthesia and any surgery include:
• Breathing problems
• Reactions to the medicines
• Need for further surgery
Problems these surgeries may cause are:
• The bones in the middle of the face may not grow correctly
• The connection between the mouth and nose may not be normal.
Before the Procedure
You will meet with a speech therapist or feeding therapist soon after your child is born. The therapist will help you find the best way to feed your child before the surgery. Your child must gain weight and be healthy before surgery.
Your child’s health care provider may:
• Test your child’s blood (do a complete blood count and “type and cross” to check your child’s blood type)
• Take a complete medical history of your child
• Do a complete physical exam of your child
Always tell your child’s provider:
• What medicines you are giving your child. Include drugs, herbs, and vitamins you bought without a prescription
During the days before the surgery:
• About 10 days before the surgery, you will be asked to stop giving your child aspirin, ibuprofen (Advil, Motrin), warfarin (Coumadin), and any other drugs that make it hard for your child’s blood to clot.
• Ask which drugs the child should still take on the day of the surgery.
On the day of the surgery:
Most times, your child will not be able to drink or eat anything for several hours before the surgery.
• Give your child a small sip of water with any drugs your doctor told you to give your child.
• You will be told when to arrive for the surgery.
• The provider will make sure your child is healthy before the surgery. If your child is ill, surgery may be delayed.
After the Procedure
Your child will probably be in the hospital for 5 to 7 days right after surgery. Complete recovery can take up to 4 weeks.
The surgery wound must be kept very clean as it heals. It must not be stretched or have any pressure put on it for 3 to 4 weeks. Your child’s nurse should show you how to take care of the wound. You will need to clean it with soap and water or a special cleaning liquid, and keep it moist with ointment. Until the wound heals, your child will be on a liquid diet. Your child will probably have to wear arm cuffs or splints to prevent picking at the wound. It is important for your child not to put hands or toys in the mouth.
Most babies heal without problems. How your child will look after healing often depends on how serious the defect was. Your child might need another surgery to fix the scar from the surgery wound. A child who had a cleft palate repair may need to see a dentist or orthodontist. The teeth may need correcting as they come in.
Hearing problems are common in children with cleft lip or cleft palate. Your child should have a hearing test early on, and it should be repeated over time.
Your child may still have problems with speech after the surgery. This is caused by muscle problems in the palate. Speech therapy will help your child.