Surgery to correct any facial deformity is known as orthognathic surgery. Orthognathic simply means straight jaws and most of the operations that I carry out to help patients with structural facial problems involve surgery to change the way the upper and lower jaws are aligned.
The surgical techniques that we now have to correct facial deformity have been developed over the last 50 years and are very safe. Although this seems like a major and frightening surgery, the results are highly predictable and many patients say afterwards that they wish they had not been so worried.
The surgical techniques that I use allow me to reset the jaw so that the position of upper and lower jaws and the chin can all be corrected, improving the way that the teeth and jaws work together for eating and speaking and boosting the long term health of the teeth and jaw bones – always aiming for the best cosmetic appearance possible.
Types of jaw deformity
The jaws can have several problems and these can affect the entire face and also compromise your speech and ability to eat and drink. Some of the most common deformities that we see are:
- Class II skeletal relationship – The lower jaw is smaller or set back in relation to the upper jaw.
- Class III skeletal relationship – The lower jaw is larger or further forward compared to the upper jaw. The problem usually arises because the upper jaw is underdeveloped compared to the lower jaw.
- Anterior Open Bite (AOB) – This is where there is a space between the upper and lower front teeth when the back teeth are touching. It can be caused by excessive thumb sucking or an overactive tongue.
- Vertical Maxillary Excess (VME) – The upper jaw is too prominent in the up/down direction. Patients find that they show too much of their upper incisor teeth and gums and have what is known as a gummy smile.
- Asymmetry – Facial asymmetry can have several causes such as overgrowth of the lower jaw at the jaw joint. This can have a major impact on the relative positions of the upper and lower jaws and chin.
What kind of surgery is possible?
Surgery to correct jaw and facial deformity have been perfected over several years and the procedures are well tested. We have a lot of evidence that they are successful as they have been used in so many patients. The surgery is usually performed through the mouth, so there are no scars on the skin of the face at all.
All of the operations summarised below are carried out under general anaesthetic. Patients usually stay in hospital just one night afterwards and can then return home to rest and recover. Careful follow-up will take place after surgery to make sure that the jaws and tissues are healing well.
Adjusting the position of the lower jaw
The most common operation used to reposition the lower jaws is the bilateral sagittal split osteotomy.
This very versatile operation allows the lower jaw to be moved forwards or backwards. The part of the jaw that contains the teeth is separated from the back part that connects with the jaw joint. Once the jaw is in its new position it is fixed with titanium metal plates and screws. Contrary to popular myth, these do not set alarms off in airports! The wounds are then closed with dissolving stitches
Moving the upper jaw
The most common operation to move the upper teeth and jaw is the Le Fort 1 osteotomy.
This is a very safe predictable operation and again, all the incisions are made inside the mouth, so no facial scars.
When the upper jaw and teeth have been separated from the rest of the face it is still attached to the body by the soft tissues of the cheek and palate. This ensures the upper jaw has a good blood supply while it is healing. The upper teeth can then be repositioned as planned and then fixed with titanium metal plates and screws and everything is sewn in place with dissolving stitches.
Surgery to reposition the chin
The operation to reposition or re-shape the chin is called a genioplasty.
This operation allows the chin portion of the lower jaw to be moved into a more cosmetically pleasing position. It is then fixed with titanium metal plates and screws and dissolving stitches are used to close all the incisions.
More complex jaw deformity surgery
If we need to move both your upper and lower jaw and maybe even your chin in the same operation, this is referred to as a bimaxillary osteotomy
The operation involves doing a bilateral sagittal split osteotomy and a Le Fort 1 osteotomy as described above, but at the same time. It is best to do both procedures simultaneously rather than one after the other to allow the facial deformity to be corrected in a safe and predictable way. The end results are much better as the position of the entire jaw can be set to give the best cosmetic outcome.
Its quite common to develop a problem with the jaw joint, known medically as the temporomandibular joint (TMJ). This joint, one of the smallest in the body, allows the bottom jaw to hinge with the top and enables us to eat and speak. We actually have two TMJ; the joints on the right and left of the face move together because the lower jaw links them together.
Around 25% of people have problems with the jaw joint at some point in life. The vast majority of problems are not related to cancer and most arise due to a build up of several contributing factors.
“The challenge that I face when treating jaw joint problems is to discover the underlying causes and then to put together a management plan to remove them from the patient’s life. This may involve lifestyle changes, self-help, relaxation, painkillers, physiotherapy, jaw joint infections or, rarely, surgery. Each case is individual,” explains Mr Hodges.
Temporomandibular dysfunction syndrome
This is a ‘catch-all’ term that can be used to describe all jaw joint problems. We tend to use it as a diagnostic term if the symptoms can be described pretty accurately, but we do not know precisely what is causing them.
TMJ problems can be divided into 3 common types. There are also a few rare conditions that affect the jaw joint: find out more about uncommon jaw joint problems
- Internal derangement
- Myofascial pain
- Degenerative joint disease
Find out more about how jaw joint problems are treated and managed by Mr Hodges.
Internal derangement
Inside the jaw joint is a thin layer of fibrous cartilage that divides the joint into two compartments: the upper joint space and the lower joint space. This layer is called the intra-articular disc or meniscus.
The meniscus usually fits on the rounded end of the jaw bone like a cap but it can shift out of position and cause problems such as:
- Clicking of the jaw
- Pain
- Locking of the jaw
If you have an internal derangement, the meniscus doesn’t stay in position on the rounded part of the jaw joint. Instead it becomes loose and is crumpled up at the top of the bone. As the jaw moves back the other way, the cap clicks back into place, causing a clicking or popping sound.
If the meniscus doesn’t pop back onto the jaw bone, it can act like a wedge and stop the jaw opening fully.
All of these problems can cause pain as the cushioning effect of the meniscus is being lost. It’s more likely that the bones move together, causing inflammation or direct damage to local nerve endings.
Myofascial pain
This condition is caused by structures around the jaw joint such as the muscles, tendons, ligaments, joint capsule and associated nerves. The underlying cause of this condition can range from over-activity in the muscles, repetitive habits, or stressful life events.
Degenerative jaw joint disease
Just like other joints in the body, the TMJ can be affected by synovial joint diseases such as osteoarthritis, rheumatoid arthritis and juvenile arthritis. These are collectively called degenerative diseases, but they don’t always affect just older people. The name reflects the fact that bone within a joint is damaged due to loss of cushioning as soft tissue disappears.
This can happen due to several disease processes, but degenerative jaw joint disease is most often caused by osteoarthritis.
The most common symptoms are pain in the face and jaw, joint noises (known as crepitus), and trouble opening your mouth fully.
Treatment depends on many factors and can range from advice on lifestyle changes, such as reducing stress, to steroid injections directly into the joint, or even to a complete surgical jaw joint replacement.