A patient who has decided to have an orthognathic treatment should understand that this surgery is a complex and time consuming process.
Ogs 2014 color
How jaw surgery, in conjunction with orthodontics, can
improve facial balance
Dr’s. Victoria Lynskey, Jerry Mogannam, &
Orthognathic Surgery (OGS)?
• Greek: “Orthos”=straight “Gnathos”=jaws
• Jaw surgery to reposition the jaws
• Result: correct jaw alignment, occlusion and
• Movement of the jaws forward or backward, up
or down, or rotated results in the movement of
the facial soft tissue of the chin, cheeks, lips
and tip of the nose
Why would a patient need OGS?
Function: Malocclusion impedes jaw function and does not allow proper
chewing of food. This might exert negative influence on food digestion and
overall body health.
OH: crowding of teeth facilitates accumulation of food debris and aggravates
maintenance of oral hygiene, therefore, teeth are more likely to be affected
by dental caries or periodontal disease.
Wear: Due to malocclusion teeth may wear out faster than usually and the
lifetime of dental prostheses may shorten.
Medical problems: extremely small lower jaw may result in snoring and
sleep apnea, which can consequently cause many health problems. In
cases of short upper lip and vertical excess of the upper jaw, the lips are
usually open & it may stimulate undesirable mouth breathing which further
TMJ: Frequently malocclusion can have strong negative effect on speech
function and often it can be accompanied by jaw joint pain.
Esthetics: occlusion and the position of jaws define the height of the lower
third of the face to the greatest extent, hence the aesthetics of the facial
profile as well. Convex ‘bird face’ or concave ‘mature face’ profiles are
considered anesthetic, therefore severe anomalies can cause social
problems if left untreated.
• Malocclusion: Skeletal vs Dental
• Severity of the skeletal malocclusion
– Orthodontic Camouflage
– Ortho tx alone: use braces and appliances to align the
occlusion irrespective of the jaw position
– Useful in borderline patients if surgery is not an option
• Overall dental and medical health of patient
• Psychosocial evaluation
• Patients from 18-45yo are the best candidates for
• We want jaws to be fully formed with no additional
• Before the age of 18, tx is limited to orthodontics and
growth modification, however, if this is not effective,
patients and parents must consent before set-up for
OGS is initiated.
• Pre-surgical ortho may worsen the malocclusion and
esthetics in order to improve the surgical movements
Malocclusion: Skeletal vs Dental
• Dental: the jaw relationship is acceptable, but the teeth are
• Orthodontics may be simple alignment or more complex, including
growth modification appliances or extractions to improve
• Mild orthodontic camouflage may be in order for borderline cases
• Ortho alone is insufficient for successfully correcting skeletal
malocclusions when the chewing function and facial esthetics are
desired in addition to occlusion
• Ortho tx alone: use braces and appliances to align
the occlusion irrespective of the jaw position
• Useful in borderline patients if surgery is not an
Skeletal: discrepancy in shape, size, and/or position of 1 or both jaws
For these patients, simple dental alignment provides little help as a
finished dental alignment will not result in occlusion because the jaws don’t
match each other
Often accompanied by an incorrect facial profile
Surgery on 1 or both jaws will correct the
improve chewing function,
enhance facial features,
and reduce any airway related problems
May be caused by genetic or environmental factors.
Types of Skeletal malocclusions:
• Evaluate the face in 3
• Sagital, or A-P (Class II,
• Vertical (Open
• Transverse (Jaw width
• Combination (including
Sagital discrepancies: Class II
– Small or retruded lower jaw, or anteriorly displaced upper jaw
– Convex Facial profile
– Airway: the airway may become tapered causing snoring and sleep
– TMJ: Patients often try mask their distal bite by thrusting their lower
jaw forward. The so called “Sunday bite” may sometimes cause
overstretching of the joint's ligaments which results in hypermobility
of jaw's joints.
– Occlusal wear: Molars may be heavily worn due to cusp-to-cusp
Sagital discrepancies: Class III
• Class III:
– Lower front teeth are edge-to-edge or in front of the
upper front teeth. May be due to a small upper jaw,
large lower jaw, or combination
– Facial profile: Concave profile with a protruding chin
and receding mid-face
– Chewing: Normal if lower teeth are in front of upper,
but may result is a shift if the front teeth are edge-toedge
Vertical discrepancies: Open Bite
• Open Bite: the molars are the only teeth to come into contact.
Often due to the incorrect position or shape of the upper jaw,
or the divergent growth profile of both jaws.
• Mouth breathers or habits contribute to this type of
• Facial Profile: is usually convex and long, causing the lips to
be strained when trying to keep the lips closed
Vertical discrepancies: Deep Bite
Deep Bite: The overlap of the front teeth is too big, and on some
occasions, the upper front teeth may completely cover the lower
front teeth. A deep bite is often the result of a small lower jaw and
incorrectly aligned teeth.
• Facial Profile: convex and the lower third of the face is short. The
upper lip may be either normal or protruding, whereas, the lower
lip is curled with a deep fold above the chin.
• Airway: sometimes associated with a reduced airway especially if
a patient has a small lower jaw.
Transverse discrepancies: crossbite
Occlusion. The upper molars positioned lingually more than the lower
molars. Most often is caused by a narrow upper jaw In many cases, a
cross bite is associated with mouth breathing.
Facial profile: The cross bite is frequently associated with an open bite
which results in a long and convex facial profile.
Airway: The airway may be tapered and the patient may have snoring
problems. Cross bite is diagnosed in children and adults who frequently
keep their mouth open because of impaired nasal breathing.
Vertical discrepancies: Gummy Smile
Vertical maxillary excess and or short upper lip
Gummy smile is an aesthetic consequence rather than a
malocclusion. It can be noticed in patients with either ideal or
incorrect occlusion. When smiling, patients show a fair amount of
gums in their upper front teeth which looks unattractive in most
• Occlusion. Occlusion may vary
• Facial profile. Usually the facial profile is convex and the lower
third of the face is long. Lips are strained when in the closed
Transverse discrepancies: Brodie Bite (scissor bite)
Occlusion. The lower molars are positioned lingually: SEVERELY.
When the mouth is closed the molars miss each other and overlap
with no contact. A possible reason for this is a naturally narrow
lower dental arch or a hyper-expansion of the upper jaw
• Facial profile. The scissor bite has no significant influence on the
facial profile. .
• Chewing function: The chewing function is bad since the molars
make no contact with each other.
Combination: Jaw asymmetry
Face. The lower jaw body is longer on one side; so therefore,
the chin obviously moved toward the shorter side. Horizontal
asymmetry usually develops when the growth of one side of the
lower jaw is accelerated. The cause for this growth acceleration is
• Occlusion. Usually there is a cross bite on one side of the jaw which
has the tendency to develop into a mesial bite. The upper dental
arch is often normal and may not be affected by the position and
shape of the lower arch.
• Facial profile. The facial profile is usually concave.
Orthognathic treatment takes about two years to complete. Once begun, it is
seldom possible to reverse or switch to non-surgical treatment, so it is
strongly recommended that the original treatment plan be completed once
The course of treatment
• Restorative/rehab: At the beginning of the treatment, teeth are restored
while, at the same time, useless teeth, as well as, the wisdom teeth are
• Pre-surgical Ortho: The orthodontic treatment is started & it lasts for about
18 to 24 months.
• OGS: Then orthognathic surgery is performed on one or both jaws, followed
then by the final orthodontic treatment which, in itself, lasts approximately 6
• Post-surgical ortho: to finish the occlusion
• Post-restorative: select teeth may receive restorations or crowns, or, dental
implants may be inserted and restored in edentulous areas
• Smile: After all this is completed, the patient will enjoy and benefit from a
stunning smile and pleasing facial features.
Orthognathic treatment: Treatment Planning
• The team of doctors is compiled: Restorative, ortho, OMFS. The
occlusion and facial features are evaluated with photographs and
measurements of the face and teeth. The purpose of this meeting is
to collect all the information that is needed to compile a treatment
plan. During this short consultation, general information about the
problem, as well as, the possible solutions are disclosed to the
patient. The individual treatment plan is then prepared during the
following 1 to 2 weeks.
• Panoramic radiograph
• Lateral ceph
• P-A Ceph
• Dental model casts.
• Articulated models
Orthognathic treatment: Pre-surgical ortho
Pre-op ortho set-up
• Preoperative orthodontic treatment takes from 9 to 18 months to complete. Braces
are bonded onto the teeth and remain throughout the entire treatment time.
• The primary purpose is to align the teeth into well-formed arches that match each
Why do patients need braces?
• The varied size and poor position of the jaws often results in an incorrect shape of the
upper and lower dental arches.
• During the many years of use, the dental arches adapt or compensate to fit each
other best, resulting in an incorrect position.
• Orthodontic treatment will align the dental arches, but the occlusion and the facial
aesthetics become worse during this stage of treatment. In nearly all cases,
orthodontic treatment is imperative since properly aligned dental arches are key for a
stable and well-established postoperative result.
When the preoperative orthodontic setup is finished, the position of the jaws is
registered with a face bow and the dental models are transferred to a an articulator.
• A simulation of the operation, based on the specified plan, is performed and a special
splint is produced and adjusted. This splint is used during the surgery and is essential
for correct and precise jaw positioning.
(I’m going to leave this up to the professionals )
Surgical Recovery: Day 1-7
First day after the surgery. New
occlusion is checked when the patient
is fully awake.
Massive facial swelling and bruises
may appear during the first two days.
Pain is easily controlled with painkillers.
Intensive antibiotic regimen is
prescribed right after the surgery to
protect the patient from infection.
Chewing is not allowed after the
surgery. One or several rubbers bands
are applied on teeth to direct the jaws
into correct position upon function.
They are tight enough to keep the jaws
in occlusion during rest but do not
prevent a person from opening mouth
Surgical Recovery: Weeks 2-8
One week after surgery. Facial swelling should be starting to
resolve on the third or fourth day.
The first postoperative visit should be done on the 6-7th day after
surgery. Wounds and occlusion is checked, elastic rubber bands are
readjusted if needed.
2 weeks post-surgery: Elastic rubber bands are also taken off for the
first time, occlusion is rechecked. The patient is trained to brush
teeth correctly and apply rubber bands according to the scheme
provided by the doctor.
3 weeks post-surgery About 80% of swelling is gone by the end of
the third week. Most of the swelling is gone in two months, however
the residual swelling in cheek area may be felt by the patient as long
as six months after surgery.
Physical work is not recommended first month after surgery,
however office work at home may be started right after discharge
from the hospital.
Final ortho treatment
Takes approximately 6-9 months.
When the jaws have fully healed up the orthodontist has to correct
the position of individual teeth. This is needed for a stable treatment
• Active post-operative orthodontic treatment can be started two to
four months after surgery. Before that time healing process is not
complete and attempts to correct the position of teeth or modify the
occlusion may have a negative effect on the overall recovery.
• Orthodontic treatment is finished when the occlusion is stable and
teeth come into correct contact. At the end of the treatment the
braces are removed but the patient still needs to wear retainers.
• After debanding, the teeth are checked and treated if needed. Some
patients may need dental implants or crowns and bridges to restore
dentition and finalize treatment.