June, 2000

A Patient’s Guide to Orthognathic Surgery

Orthognathic surgery is an unfamiliar term to most people. This booklet is designed to give you better understanding about the purpose, procedures, and results of orthognathic surgery.

En Español

Dr. David Sarver

Editor’s Note

Orthognathic surgery in conjunction with orthodontics and other dental disciplines is a confusing and sometimes frightening concept for many patients. For those people who need surgical correction the alternatives are few. These patients need to be educated in terms that they can understand but yet do not fail to give them detailed insight into what they will be facing. Presented here is Dr. Sarver’s handout for patients (and their families) contemplating orthognathic surgery. This is COPYRIGHTED material and is not meant for use in your office, but is presented as a model to emulate. Use this example as a guide for constructing your own information handout. The Orthodontic CYBERjournal thanks Dr. Sarver for sharing work that obviously has taken a great deal of time and effort to put together.

Raymond Bedette, DDS, Co-Publisher
The Orthodontic CYBERjournal

Preface

Orthognathic surgery (jaw surgery) is a term and a process unfamiliar to most people. When orthognathic surgery is recommended to you or your child, you want as much information as you can possibly get. We have been leaders in this field of dentistry for 30 years, and in that time have encountered many myths and misconceptions patients gather through conversations with friends and neighbors and exploring the Internet. This booklet is designed to give you a clear picture about the purpose of the recommended procedures, and present a clear description of the procedures in orthognathic surgery. It is our goal for you to feel completely informed and comfortable with your treatment, so we have designed this booklet to take you step-by-step, from start to finish.

The purpose of orthognathic surgery is to correct functional and esthetic problems that are due to underlying skeletal deformities. Why is it important to correct a bad bite? Severe malocclusion (bad bite) may cause many functional problems. You may have already experienced some of the following: inability to chew food properly which compromises digestion; speech problems; facial dysfunction characterized by headaches, joint pain, and periodontal trauma. Orthognathic surgery is also an important part of the treatment of obstructive sleep apnea.

Before we talk about orthognathic surgery there is something important for parents to understand!

Orthognathic surgery if often the treatment solution in cases where the bite problem is so severe that orthodontic treatment alone isn’t enough to correct the problem, or where orthodontics alone would compromise your facial appearance. An important note-it is important that we see children earlier than our generation of parents was accustomed to. When we as parents were children, the patient did not go to the orthodontist until all the permanent teeth were in. Modern orthodontic treatment is more than just straightening teeth. We now evaluate the dental relationships much as we did in the past, but now evaluate facial growth issues as well. Here is the important point-the eruption timing of the teeth does not correlate to skeletal growth. We often see 10-year olds with all their permanent teeth, and 14-year olds who have only the permanent incisors in. This means that a child with a jaw growth problem (an undergrowth of the lower jaw, for example) get’s treatment for the growth problem at the right time, and this may need to be timed separately from how the teeth are developing.

This means three things to parents:

  • It is important to see the orthodontist early. (age 7 is recommended by the American Association of Orthodontists)
  • The overall orthodontic treatment outcome can be functionally and esthetically better than 30 years ago.
  • Jaw surgery itself may be avoided in many adolescents through contemporary orthodontic treatment, appropriately timed, by correcting the growth pattern during the patient’s growth period.

Let’s illustrate this with two patients:

Overjet

This term means the lower teeth are horizontally behind the upper teeth. Most people refer to this as a bad overbite, but orthodontists refer to this as overjet and classify it as a Class II malocclusion. Overbite is the vertical depth of the bite.

This adolescent male has a Class II malocclusion. The cause is an undergrowth of the lower jaw and is a reflection of his inherited genetic pattern. The growth problem is the reason he has a malocclusion and this is reflected in his facial profile. His lower jaw is also underdeveloped vertically causing a short facial height. Orthodontic treatment is directed towards correction of his bite with growth modification utilizing orthodontic appliances and night-time wear of a headgear. In this case, treatment resulted in bite correction and facial improvement.

Overjet Before and After
Overjet: Before and After

Overjet Diagram

Underbite (or Negative Overjet)

This problem can be successfully intercepted with appropriate timing of treatment. An underbite is the opposite of Class II malocclusion with the upper teeth actually hitting behind the lower incisors and is referred to as a Class III malocclusion.

This adolescent female was followed until the appropriate time to treat her skeletal problem-underdevelopment of the upper jaw. Using a palatal expander and reverse headgear in her early years, followed by braces later, she was treated successfully to a good bite and balanced face with another form of growth modification-mid facial protraction.

Patient cooperation is absolutely essential to successful treatment, whether in adolescent or adult treatment. Orthognathic surgery provides us with the opportunity to improve both functional and cosmetic problems at the same time. Most aren’t familiar with the procedure and are uncomfortable in considering it as a treatment option. Again, the information in this booklet is designed to take you step by step through the process involved with orthognathic surgery so you can fully understand the entire orthodontic and surgical experience.

Underbite Before and After
Unterbite: Before and After


General Information & Sequence of Treatment

The Initial Visit

On your first visit we will discuss your chief complaint. We would like to emphasize that we believe that we have several responsibilities to you as a patient. First, we want to talk with you as to what you are looking for in treatment. Relief of pain, restoration of dental function, esthetics-all may be parts of what you are looking for. Next, we want to be sure we educate you as to all your treatment option. Finally, we want to guide you to the treatment plan that is tailored for you. But we believe that part of our professional responsibilityis to not only help you decide what is best, but exercise our professional judgment as to what might be inappropriate for you. In other words, we must help you decide on what is best for you, and what might be a bad decision too!

To accomplish this we have the latest technology. Through the use of digital imaging and radiography, we can assimilate your diagnostic information very rapidly. We can outline treatment at the initial visit in a visual package that is in language you can understand.

Improved Self Esteem
One of the most rewarding aspects of orthognathic surgery is improved self-esteem.


DIAGNOSTIC RECORDS

At the first visit, a set of diagnostic records will be taken to determine the nature of your problem and what can be done to correct that problem. After processing and analyzing those records, we will meet with you for a consultation appointment to discuss your treatment options. The following explains the individual records that may be taken and what their purpose is:

Contemporary Imaging

We use digital photography rather than film, which gives us instant documentation of your dental and facial relationships. We utilize contemporary digital imaging software which allows us to illustrate changes you might anticipate and want to occur or not.

Digital Radiography

Digital radiography has several advantages over film. It is virtually instant, requires significantly less radiation, and can be forwarded to your dentist or any other professionals via digital transmission in its original high quality state-not a reduced quality copy. Digital radiography also allows us to enhance the images for better recognition of the anatomy, a real diagnostic advantage.

We have also just recently installed state-of-the-art, three-dimensional “regional” digital radiography that allows us to visualize areas of interest in 3-D, without the radiation exposure and cumulative radiation of a full CT scan.

Photographs

Frontal, oblique, and side facial photographs are part of the overall work-up of the case. These facial pictures serve as visual aids for bony and soft tissue analysis so that the facial aspects of treatment can be thoroughly evaluated. Photographs of the teeth will also be taken to provide an accurate record of the mouth at the time treatment begins.

Patient Photographs (Frontal, Side, Oblique)
Patient Photographs (Frontal, Side, Oblique)

Cephalopmetric (Lateral Skull) Radiograph

This side view radiograph of the face allows us to compare your tooth and jaw relationships to normal or ideal measurements. Computerized analysis permits prediction of planned bony movements and subsequent soft tissue response though the merger of the facial pictures with the cephalometric radiograph. This permits us to show you the facial changes which you might expect with treatment.

Lateral Skull Radiograph and Analysis
Lateral Skull Radiograph (left), Computer Analysis (right)

Panoramic Radiograph

The panoramic radiograph is a composite radiograph of the teeth as well as both jaws. In one film, it shows us if you have the normal number of teeth, wisdom teeth, missing teeth, impacted teeth or extra teeth.

Panoramic Radiograph
Panoramic Radiograph

Study Models

Dental models will be used to study the dental problems as they exist at the beginning of treatment and are used for reference during pre-treatment planning. In many cases, the models are placed on an articulator, a device that closely simulates jaw movement.

3-Dimensional Radiography

Frequently your orthodontic and surgical planning requires much more than a radiograph of the profile. The utilization of 3d “Focused Field” radiographic technology allows us to assess dental and skeletal structures in three dimensions with minimal radiographic exposure. As illustrated, we can see the parts of the teeth and jaws we want a more specific view of, which makes our recognition, diagnosis and planning as complete as possible.

3D Radiography

Digital Movies

Also as part of our analysis, we capture digital movies. We use software to break the smile action into elements for smile design, which gives us more complete information than a single photograph.

Digital Movie Captures

3-Dimensional Facial Map

This non-radiographic image of the face allows for 3-D analysis through rotating the image to investigate the patient from all angles. A great research tool as well, this technology gives us unparalleled insight into the soft tissue responses to our orthodontic and surgical movements.

3D Facial Map
3D Facial Map

Computerized Digital Imaging

At the time of your consultation visit, we will utilize digital imaging in the discussion and planning of esthetic changes. In this process, a digital picture is modified to illustrate approximate profile changes, which may occur in your proposed treatment plan. Also, other options of treatment may be illustrated at this time.

Computerized digital imaging allows the patient to see the projected changes anticipated with the proposed treatment.

Computerized Digital Imaging
Before profile (left), Prediction of orthodontic/surgical outcome (right)


Before and After
Before and after photographs.


Consultation Appointment

While surgery may be the best option to achieve desirable functional and cosmetic results, it is always an elective procedure. Other treatment options will be presented to you in the consultation appointment. In this visit, we will discuss:

  • The overall analysis and problem list
  • Treatment objectives
  • The anticipated treatment sequence
  • Optional treatment plans and their strengths and weaknesses relative to your overall treatment objectives

Because treatment in adults often involves more complex problems, referrals to other specialists may be necessary. Also, if we find that tooth removal is required for orthodontic purposes, a referral will be made to your dentist or oral surgeon at that time.

When do you do surgical-orthodontic treatment?

Prior to adolescence, surgery is almost exclusively for children who have congenital deformities or problems related to trauma. For children with severe growth distortions, guiding growth is better than surgery, if it is possible. So surgical orthodontics rarely is indicated before the adolescent growth spurt ends. That doesn’t always mean surgery has to wait until all growth has ended. Jaw surgery has surprisingly little effect on growth. So if the problem is deficient growth of the mandible (Class II) or maxilla (Class III) surgery prior to completion of growth may be possible. In other words, when deficient growth is the problem, it isn’t necessary to wait until age 18 or 20 for jaw surgery.

Insurance Authorization/Predetermination

We will be happy to help you with insurance processing and will discuss flexible financial arrangements for uncovered procedures. Also, a copy of your radiographs will be provided for the oral and maxillofacial surgeon to submit to your insurance company for pre-authorization of available benefits. This determines the extent of your insurance coverage in orthognathic surgery. In the majority of cases, your insurance carrier should cover hospitalization, anesthesia and surgical fees, but may not cover the orthodontics required for successful treatment.

We will be glad to assist you in filing your insurance, but we cannot guarantee it will cover your orthodontic care. What is the biggest problem at present with surgical-orthodontic treatment? It’s financial, not related to the treatment itself. Until recently, medical insurance typically covered the surgery and the associated hospitalizations. Under standard medical insurance plans it still does, which is reasonable enough, given that the underlying problem is a jaw deformity, not unlike a congenital deformity of any other part of the body. But with benefit reductions and HMO contracts, in many areas jaw surgery now is denied, admittedly as a cost-reducing measure. As a result, most surgeons offer outpatient services and payment plans in an effort to make these procedures affordable even without insurance coverage. You will need to consult with the surgeon’s office as to how you and your insurance company can communicate you needs clearly.


Orthognathic Surgical Procedures

There are three general types of orthognathic surgical procedures utilized in our surgical cases:

  1. Sagittal Split Osteotomy of the Mandible
  2. Lefort I Osteotomy of the Maxilla
  3. Genioplasty or inferior border osteotomy of the mandible (chin advancement)

This section will describe all three procedures to facilitate your understanding.

Sagittal Split Osteotomy

This operation is performed on the lower jaw (mandible) in order to move it forward (in the case of a deficient lower jaw), or backward (in the case of a large lower jaw). It is performed behind the back teeth (not in the joint) and the jaw is sectioned in such a way that bony contact is always maintained. There are no gaps in the bone that have to be filled in, and it is not necessary to wire your teeth together during the postoperative healing period. Our surgeons have routinely utilized Rigid Internal Fixation (RIF) since 1985 for the stabilization of osteotomies. This technique eliminates the need for wiring the teeth together during the healing phase.

Advancement of the Lower Jaw

The lower jaw can be lengthened through a Bilateral Sagittal Split Osteotomy, which allows bony contact throughout the procedure and permits placement of direct rigid fixation-which means the teeth are not wired together and you can open your mouth after surgery.

Advancement of the lower jaw
Before and After

Reduction of the Lower Jaw

The lower jaw can be shortened through the use of the Bilateral Sagittal Split Osteotomy, which allows bony contact throughout the procedure and permits placement of direct fixation. As illustrated before, a small segment of bone is removed so that as the lower jaw moves back, the bony contact in the surgical site is maintained for a rapid healing and ultimate control of the bony segments.

Reduction of the lower jaw
Before and After

Rigid Internal Fixation utilizes compression screws or plates which allow the surgical team to avoid wiring the teeth together.

Rigid internal fixation


LeForte I OsteotomyLeForte I Osteotomy

This operation involves the upper jaw (maxilla) and the movement of it in various directions. This procedure is used in the treatment of:

  • Long-face problems
  • Short-face problems
  • Open bite
  • Horizontal maxillary protrusion (overbite)
  • Horizontal maxillary deficiency (under bite)

Treatment of Long-face and Gummy Smile

Many gummy smiles can be a result of short teeth, a short upper lip, upright maxillary incisors, an excessive mobility to smile, and vertical overgrowth of the upper jaw. The vertical overgrowth of the upper jaw is often referred to as the “long face syndrome” and is characterized by a long lower facial third, an inability to get lips together at rest, and a gummy smile. The long face syndrome or vertical overgrowth of the top jaw is very often accompanied by an open bite malocclusion, and surgical correction of the bite is performed through the Lefort I Osteotomy where the upper jaw is moved upward to close the bite, which in turn diminishes the amount of gumminess of the smile.

Long Face and Gummy Smile
Long Face: Before (top), After (bottom)

Treatment of Short Face

Just as an upper jaw may grow too far vertically, in many cases, it may not grow vertically enough. This is in turn characterized as the “short face syndrome” and is characterized by a short lower facial third and incomplete incisor display on smile. The short lower facial height is well illustrated by this case, where lengthening of the face provides a better proportionality as well as improving the url to the lower lip (referred to as the labiomental sulcus). In the case illustrated below, this patient had a Class II Malocclusion with severe overjet, and lower jaw advancement was needed to fix his bite and upper jaw surgery was required to bring the upper jaw down to increase his lower facial height and improve his smile.

Short Face
Short Face: Before (top), After (bottom)

Open Bite

Open bites are among the most difficult dentoskeletal patterns for orthodontists to treat.a The surgery to correct an open bite in the adult involves a Maxillary Osteotomy, usually impaction of the back part of the upper jaw, allowing the lower jaw to rotate closed.

Open Bite
Before (left), After (right)

Horizontal Maxillary Deficiency (Underbite):

Most underbites are a result of underdevelopment of the upper jaw. In this case, the maxilla was moved forward surgically, and a rhinoplasty performed at the same time since moving the upper jaw forward sometimes results in an excessive widening of the nose.

Underbite
Underbite: Before (top), After (bottom)

An underbite can give the appearance from the front as a “bulldog” appearance, and in this case the upper jaw was surgically moved forward to fix the malocclusion and brought down some to dramatically improve the smile.

Underbite
Underbite: Before (top), After (bottom)


GenioplastyGenioplasty

This operation involves the movement of the chin, which may be moved forward, back, or upward to shorten it, or downward to lengthen it. The choice depends almost entirely on how it might affect your ability to let your lips relax together and on how it affects your facial appearance. Because it involves the bottom portion of the lower jaw, this procedure may also be referred to as an inferior border osteotomy. This procedure is not a chin implant. It is part of the lower jaw that is repositioned and is not a foreign body. Sometimes the genioplasty is confused with actual jaw surgery. It is a much less complicated procedure and can be done at any time. Orthodontic treatment is not necessary for this procedure.

Genioplasty: Before and After
Genioplasty: Before (top), After (bottom)

Genioplasty: Before and After
Genioplasty: Before (top), After (bottom)


The Team Approach

The level of sophistication in dentistry, orthodontics, and oral maxillary surgery has increased dramatically in the past decade. This is partially because of improved techniques and technology, but is due primarily to the increased cross-fertilization of knowledge between the specialties of dentistry and medicine and excellent communication between these groups.

To achieve maximum results, collaboration between Drs. Sarver, your dentist, oral and maxillofacial surgeon, and plastic surgeon can be facilitated through graphic imaging and interdisciplinary planning. Dr. Sarver and colleagues have pioneered this approach to treatment here in Birmingham. Dr. Sarver’s books, Esthetic Orthodontics and Orthognathic Surgery and Contemporary Treatment of Dentofacial Deformity are used by the various medical and dental disciplines in teaching as well as clinical practice.

This approach is more than “just teeth”. It is a comprehensive approach to treatment to capture the result most desirable to the patient. The use of digital imaging and computers provides excellent interaction with you, the patient, to design just the right type and amount of treatment you might desire.

The case pictured below is an excellent example of this teamwork concept. This patient had a Class III malocclusion (underbite), and to correct her malocclusion, orthodontic treatment and orthognathic surgery was needed. She also had malformations of her tooth enamel and porcelain veneers were planned as the finishing procedure. The sequence of treatment was to start with orthodontic preparation and tooth alignment, and when ready for surgery, the interdisciplinary team communicates as to the overall surgical plan. Once her postoperative orthodontic treatment was completed, her braces were removed and she then saw her dentist to bleach her teeth to attain the most ideal and natural shade for final planning of her cosmetic dental phase of treatment. In our finishing evaluation, we felt she would benefit from periodontal crown lengthening for better tissue health and a better smile with better tooth dimension. Once healed, the final phase of treatment was porcelain veneers to restore the malformed teeth.

From this case, you can see the importance of coordination of care, and careful communication was essential to this beautiful outcome. Drs. Sarver work closely with their team members to achieve these life-changing results.

Before and After
Before (top), After (bottom)

This patient’s treatment required collaboration of many doctors. Because of the complexity of her problem, we prepared her orthodontically for advancement of the upper jaw to correct her underbite by the oral and maxillofacial surgeon. At the time of her operation, her chin was advanced and her nose improved by the facial plastic surgeon. When we finished the orthodontic treatment, her teeth were lengthened by a periodontist, and her dentist completed the treatment with porcelain veneers because of the congenital dental malformations she had.


PRESURGERY / SURGERY

The following is a general sequence of events that occurs once your treatment begins. Please remember that each treatment plan and case may vary from this general sequence of events.

Presurgical Orthodontics, Orthodontic Appliances (Braces)

In order to prepare your teeth for your orthognathic procedure, we will place braces on your teeth to begin their alignment. The purpose of the presurgical phase of orthodontics is generally to:

  • Align crowded teeth
  • Decompensate incisors (align them properly within the jawbone)
  • Coordinate the teeth so they will fit when the surgery is performed

Presurgical orthodontics may take as few as 6 months or as many as 18 months, depending on your needs. During your treatment, impressions will be taken in order to check the progress of the orthodontic alignment. These impressions are referred to as surgical check models. Once we feel your presurgical goals have been accomplished and have placed an archwire heavy enough for surgery, we will then make an appointment for your surgical work-up.

The Surgical Work-up

When the presurgical phase of orthodontics is complete, radiographs, photos and models will once again be gathered at this important appointment. We will also contact your surgeon’s office to find out approximate dates available and to initiate final insurance approval, if it is required. Our final surgical plans will be determined from the work-up records. Dr. Sarver and your surgeon will consult to decide on the recommendations they will make to you to achieve the best results. Superimposition of your profile video image and X-rays will serve as a valuable guide for achieving your desired esthetic goals. From the surgical check models, a plastic splint, called the occlusal wafer, will be fabricated for the surgeon as a guide for the desired tooth relationship.

Orthodontic Appliances

The purpose of the presurgical phase of orthodontics is to align the teeth so the bite is correct when the surgery is complete. At the time of surgery, we will place surgical pins which are threaded through a special slot in your orthodontic brackets. These serve as an attachment during the surgery for the surgeon to be able to secure the teeth. The braces are not removed before your surgery.

Sequence of Treatment Events

  • Diagnostic records and analysis
  • Insurance predetermination and treatment plan confirmation
    • Consultation with oral and maxillofacial surgeon
    • Consultation with dentist, other specialists if needed Placement of orthodontic appliances (braces)
  • Presurgical phase of orthodontics
  • Presurgical work-up and analysis
  • Appointment with surgeon(s) to select surgical date
  • Surgery and postoperative rehabilitation Finishing orthodontics
  • Removal of braces, placement of retainers
  • Final dental equilibration, restoration, and cosmetic finishing

The Surgery

Day of Surgery

Generally, you will be admitted to the hospital the morning of your scheduled surgery. The length of your surgery depends on the procedure being performed. The length of your hospital stay also varies according to your procedure. Some procedures may be done on a 23-hour outpatient basis. Your surgeon should discuss with you all these necessary details prior to your surgery.

Anesthesia – General

There are many side effects to general anesthesia that you may possibly experience after surgery. These include some weakness, dizziness, and nausea. Drugs are generally administered during and after your surgery to prevent nausea. We must emphasize that this side effect is very rare, and is generally controlled with medicine. We would also like to point out that after general anesthesia is administered, there may be a feeling of depression several weeks later. Please be aware that this may happen and do not be alarmed. Make sure your family is aware of this as well.

Intubation

Your anesthesia will be administered through nasal intubation. In other words, a tube is passed through your nose to the lungs to administer the anesthetic agent. A tube is also passed to the stomach in order to keep the stomach empty before, during, and after surgery to help control nausea. You should expect to have a sore throat for 1-2 days following your procedure due to the intubation.

Intraoral Incision

Incisions are made on the inside of your mouth for access during the surgical procedure. As a result, there is no external scarring. These incisions are typically located in the folds of tissue and are not usually visible after your surgery. The sutures used on the incisions either dissolve or are removed after 5-7 days.

Intravenous Fluids (I.V.)

Intravenous fluids are administered at the time of surgery. The I.V. is used during surgery to maintain adequate fluid levels and is used after surgery to administer pain medication, antibiotics, etc. It is generally removed the day after surgery.

Post Surgery

We do everything we can to make your surgical experience as comfortable as possible. There are several things you can do to help. Here are also things you should expect.

Swelling

The amount of postoperative swelling which occurs varies from person to person. It appears to be greater in the second or third day after surgery and tends to decrease thereafter. Swelling may be present up to 6 months after your surgery, but generally is only noticeable up to 6 weeks. In order to minimize swelling, we suggest:

  1. Ice compresses: It is most important that ice compresses be in place the first 12 hours after surgery. Place ice around the operative site several times a day to reduce the amount of swelling which occurs in the first week. Your surgeon can arrange for a nurse to be available for this.
  2. Elevation of head: (The first 2 weeks after surgery) The head should be placed at a 30-45 degree angle while sleeping. This will reduce the amount of fluid accumulation in the jaws at night.
  3. Steroids: Your surgeon may recommend the administration of steroids to reduce the amount of swelling, which also reduces discomfort.
  4. Increasing activities: Walking and “getting back to normal” increases blood flow, which helps to disperse swelling. We encourage all patients to begin normal walking and other activities which would increase their blood flow. However, do not resume vigorous activities such as jogging, working out, or other sports until your surgeon gives you approval.

It is not uncommon for you to experience a brief period of “the blues” several weeks after your procedure. This mild depression may be due not only to the general anesthesia, but to changes in diet as well. Another factor may be the response from your friends and relatives. Your friends and relatives should be aware that there is going to be a change in your appearance and that gradual adaptation to the surgery will occur. Please caution your friends and family that final judgments of the end result should not be made for many months. Also in advance, you should inform them of what should be expected with your procedure.

Post-op Guidelines

Resuming Normal Activities

Most patients return to work or school one week after their procedure. (Obviously, the more extensive the surgical procedures you have, the more recuperation time you will probably need.) Physical activities such as jogging, working out, etc., should not be resumed for approximately 3 months. Walking and other more moderate activities are certainly encouraged in order to increase your blood flow to reduce swelling, as well as to improve your frame of mind.

Oral Hygiene

Strict oral hygiene maintenance is essential. If you do not keep your mouth clean after your surgical procedure, you greatly increase the chance of an infection occurring. Use a soft bristle brush, preferably with a very small head (child’s toothbrush), and clean above the brackets and around the orthodontic archwires as effectively as possible. Please take great care not to hit the incisions, since this could possibly disrupt blood flow to the surgical site. We do not recommend the use of a Water Pik-type device since it may be difficult to control the water pressure. Utilizing the fluoride rinse given to you by our office when you have your braces placed is also strongly recommended.

Diet and Nutrition

These guidelines will be provided by your surgeon. We will provide you with a basket of foods that will be sufficient for your first postoperative day. This will also serve as a guide to what types of foods you might need.

Postoperative Visits

We will want to see you one week after your surgery to check the position of your bite. We will also take postoperative panoramic and cephalometric radiographs to check the position of the bones. Very rarely are there any archwire changes made at this appointment, but some training elastics may be recommended.

Postoperative Orthodontic Treatment

Orthodontic treatment after surgery usually takes between 6-12 months. Studies show that surgery patients can experience a mild depression at the 6-month postoperative period if the braces have not yet been removed. This depression is not an abnormal psychological response to treatment and should be anticipated.

Appliance Removal and Retainers

This is the day you have waited for-the day your braces are removed! Most often, a fixed retainer will be bonded to the inside of the lower front teeth before removing the braces. The upper retainer is usually removable. One week after removing your braces, you will receive this retainer and instructions on care and use.

Final Records

Once your treatment is complete, a set of final records will be taken. These records consist of the same records taken at the time of your initial visit. This appointment is generally 1-2 weeks after your braces are removed.

Retention & Recall Visits

Further appointments with Dr. Sarver are necessary after your braces have been removed. These periodic visits will be every 3-6 months and are necessary to adjust your retainer and check your bite. Because of the special nature of orthognathic treatment, Dr. Sarver prefers to follow his surgical patients for many years after treatment. Retention is the crucial part of your orthodontic treatment. Retainers are to be worn at all times during the first few months to one year following treatment. Once you have reached a point where your teeth and bones have stabilized, you will be able to limit the wearing of your retainer to only while sleeping. Keep in mind, however, that the more the retainers are worn, the less chance there is of anything moving out of place.

Equilibration and Final Restorative Dentistry

In some cases, “equilibration” may be needed. Equilibration is simply the “fine-tuning” of your bite and is done by your dentist. Any bridges, replacement crowns, etc. should also be done at this time.

Coordination with Your Dentist

Many patients requiring orthodontic/surgical treatment of their malocclusion also require sophisticated dental care to be closely coordinated with the treatment. Your dentist will be consulted and called upon to help shape the goals of your treatment, and in many cases provide treatment from major dental reconstruction to the “finishing touches” that make a big difference in both your functional and esthetic outcomes.

Various procedures: Before and after

Before and after

Questions & Answers

How much pain will I experience?

Pain varies from individual to individual. Some patients describe the pain to be more of a “soreness,” but most patients term the experience as more of a “discomfort.”

How long will I experience this discomfort?

Discomfort is to be expected and generally lasts 2-3 weeks. It is more noticeable the first few days after your surgery, but you will feel an improvement every day. Your surgeon may prescribe some medication which will help minimize this uncomfortable feeling.

Will there be any scars?

The major incisions are done inside your mouth and are approximately one centimeter long, so no outside scars should be expected.

Will my teeth be wired together?

No. Many years ago, it was necessary to wire patients’ teeth together during the postoperative healing phase. In 1984, we began the use of rigid internal fixation (described on page 6), which eliminates the need to wire the jaws together. You may begin to open and close your mouth, fairly normally, right after your surgery.

When will I be able to eat solid foods?

Immediately following surgery your diet is limited to soft foods. With a creative imagination, you will not be as limited as you might think. Your surgeon’s office should provide you with more guidance on such a diet. Examples of soft foods:

  • Baked potato with melted cheese
  • Most cooked pastas with mild tomato or cheese sauce
  • Cream soups with very soft vegetables

Because the muscles in your mouth are not very strong immediately after the surgery, and your new bite feels different, it may be more difficult to chew. Foods such as breads and most meats will be difficult to eat. About 4 weeks after surgery, however, your surgeon will recommend trying more normal foods.

How long before I will feel comfortable going out in public?

As far as your appearance is concerned, any bruising that may occur will be gone after a few days. Swelling, however, takes longer to dissipate, but most will be gone after approximately 2 weeks. You will be much more conscious of your appearance than will the people around you. Although your family and close friends will notice a change and their reactions may vary, remember that the swelling will decrease every day, and after 2 weeks the majority of swelling should be completely gone.

How long will I miss work or school?

The length of time you are out of your normal everyday activities varies based on several factors.

  • Age: Youth is an advantage, as with any surgery; however, attitude plays a very large part in the recovery process.
  • Attitude: A positive attitude increases your ability to snap back from the procedure. Be active; follow with a healthy diet.
  • Procedure: The type of surgical procedure performed and the length of the procedure also influence recovery time.
  • Occupation: A physically demanding occupation will require more recovery time before returning to work, as will an occupation which requires constant talking. The average patient is able to resume daily activities after approximately 1-2 weeks, in moderation.

When can I resume exercising?

It is necessary to gradually build back up to your exercise routine. If you do aerobics or jog (high impact), you will need to start out with walking in moderation. It is recommended that you walk very soon after surgery to aid in the recovery process. This activity increases circulation and muscle strength.

Will it be difficult to talk after the surgery?

You should expect some soreness in lengthy conversations; however, the more you talk, the more you exercise your weakened muscles and aid your recovery. You may be sore but try not to depend on writing notes to communicate. Go ahead and say it!

How soon after surgery will I get my braces off?

This depends on the complexity of the procedure and type of problem you have. Studies show that people grow very impatient with the braces at 6 months postoperatively and can become depressed if the braces are not off by then. You can insure that your braces come off as soon as they can by keeping appointments and wearing elastics as prescribed.

What is left to be done orthodontically after surgery?

With the use of elastics and different archwires, we will complete final bite detailing. There is often some space closure and final root positioning left to be done the last few months as well. Cooperation from the patient during this time will play a large part in the completion of treatment. Please remember we want your results to be as excellent as possible. So please be patient; we want to do a good job!


Contributed by:

Dr. David Sarver
Dr. David Sarver, graduated from the University of Alabama School of Dentistry in 1977, and was named by ODK as the Outstanding Professional Student in the Medical Center. He completed his certification in orthodontics at the University of North Carolina, where he also obtained his postdoctoral master’s degree in 1979. He then opened his practice in Birmingham in 1979. Dr. Sarver is a Diplomate of the American Board of Orthodontics, a member of the Angle Society of Orthodontists, and currently serves as an adjunct professor at the University of North Carolina. He has authored the orthodontic text Esthetic Orthodontics and Orthognathic Surgery, which is used in clinical and university teaching. He and his wife,Valerie, have three children-Dave, Leigh and Suzanne.

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Comments 105 Responses

  1. anny

    09. Sep, 2012

    oh my god ’’’’’’’’’’’’’’’’’’’’’’ i am so scared to do this surgery :(

    Reply to this comment
  2. Bernz O.

    25. Sep, 2012

    Hello,
    I have a Malocclusion III, I have been planning to have a jaw reduction but I have not found a case similar to mine. I have a full lower denture and partial upper denture. Where do I go for check-up? I have blue cross blue shield insurance and I live in Texas. I also have a TMJ and it’s really hurting me more now as I get older. I am 36 yrs. old. Will it be covered by my insurance? Hope for your response.

    Reply to this comment
    • Alexis

      14. Dec, 2012

      I just had corrective surgery covered by BluCross BluShield, but in Louisiana. You should make an appointment with an oral surgeon, they will file insurance paperwork for you and tell you exactly what you’ll need to correct your condition.

  3. betty sosh

    03. Oct, 2012

    my granddaughter is 13 she has a crossbite overbite and bilaterial bite they say if its not fixed it could cause damage to her jall bone so they are sending her tluniverstey of louisville,ky will they have to break her jall to fix this problem then will they have to wire her mouth shut or how do they go about fixing this im really worried

    Reply to this comment
  4. Ashley

    04. Oct, 2012

    Hi! I want to share a positive experience! I’m 32 and just had upper and lower jaw advancement with widening of upper jaw, genioplasty, and septum/turbinate reduction. I breezed through it…don’t regret a thing…would recommend it to anyone…BUT…make sure you get several opinions, talk to people in the dental community and look for a good referral! I owe my easy procedure and recovery all to my orthodontist and oral surgeon! Make sure your orthodontist knows what they’re doing first of all…find out how many surgery cases he/she has handled…and make sure they work closely with and are particular about the oral surgeon they use. Make sure the oral surgeon has done many cases. My oral surgeon happens to be a certified cosmetic plastic surgeon as well…they know better how to make things aesthetically pleasing to the eye in addition to putting the jaws in a functional relationship…which is more important than aesthetics, btw, but you also don’t want to end up with a chin that sticks out after they’ve moved your lower jaw forward…which would have been the case with me without the genioplasty. I can say I had minimal pain with my procedure…I had some pain meds the day of my surgery, but took ZERO pain meds after that….not even OTC. Swelling and numbness is mostly just annoying. Had some post nasal discharge that was annoying but subsided within a few days with steamy baths and warm compresses. Other than that I have felt great, eaten well, and healed super fast! Still have some swelling but am only 1 week and two days piost-op. I’m able to take the bands off three times a day to eat and brsh. Only eating foods I can fit in in my mouth with a spoon and swallow without chewing. The first week is all I had to endure eating liquids/purees from a syringe. I love my new bite and profile…I can breathe so much better….and am hoping I wil never get a migraine again! My advice to surgery candidates: don’t get nervous, take everything in stride, expect some discomfort, be prepared for the eating change, follow all your doctors’ orders, and most if all…STAY POSITIVE!!!! It works wonders on the healing process!! Please remember to BE PATIENT. You won’t look like yourself again overnight….you won’t get your feeling back overnight…you won’t have all your strength back right away…be patient and positive and it all will come so much quicker!! Also be real about the risks associated! It’s in plain black and white that you may lose feeling permanently…you sign that informed consent before the procedure so it irritates me seeing people complain about it like they didn’t know. If it truly wasn’t disclosed then you might gave a GOOD lawsuit going. If you missed it…its your fault. Do your research on the procedure, the risks and benefits, and your doctors before you start treatment! Good luck to all!! :-)

    Reply to this comment
    • Alley

      10. Dec, 2012

      How much did it cost hand did u have insurance coverage since you r not a minor

    • Linda

      27. Jan, 2013

      Ashley
      I really appreciated you taking the time to tell to us about your surgery. I was told I needed this awhile ago and just cannot make up my mind. I have to see a chiropractor every6 to 7 days or I get horrific headaches. (I have an underbite.) And it took me MANYyears to find something that worked for me but I am tired of going and it runs my life. However, I am in my 50′s and I am afraid of surgery to begin with. Can you please get back to me and tell me if you had to have your mouth wired shut? i read Dr Sarvo’s work that says you do not have to have this done anymore but my surgeon, who has done a million of these at Kaiser, says my mouth has to be wired shut for two weeks. CAN YOU IMAGINE? What if I get sick after the surgery? Thanks so much for your entry.

    • rima

      10. Apr, 2014

      Hi Ashley, my daughter needs orthognathic surgery, trying to find a good oral surgeon, from your experience I can learn that a surgeon with plastic surgery background will be my best choice, so can you get the name of your surgeon please, thanks

  5. Allison

    06. Oct, 2012

    hey i was just told a few days ago that i need jaw surgury…. i am 14 and extremely nervous and i dont know what to do… HELPPP!!!

    Reply to this comment
  6. George

    23. Oct, 2012

    Hi all.

    Reading this website was so helpful. I am currently in the braces stage (had them on for 18 months now) and now i’m waiting for my orthodontist to say i’m ready. I’ve got an underbite but I have to have both upper and lower jaw done, think i’m one of the lucky ones! Anyway fingers crossed I get it out of the way soon and thanks for the info!

    Reply to this comment
  7. Bobbi Jo

    12. Nov, 2012

    My duaghter is having lower jaw surgery on December 5th, she has to be wired shut for 3 weeks, I am hoping the 3 weeks go by fast , I see a lot of people are getting banded and wish that is what they would do for her. Wish her luck!

    Reply to this comment
  8. Kristy

    01. Dec, 2012

    I am a month post op from having surgery on both my top and bottom jaw to correct my bite. At a month post op I am still taking Ibuprofen and Tylenol round the clock to try to control my pain. The recovery from this surgery is much longer than what I was told. I have not been comfortable since the surgery due to the numbness, the wires for the bands poking into my gums, not being able to sleep laying down etc. I am miserable and do not feel that my surgeon or orthodontist know what they are talking about when they told me I would be able to go back to work and would feel good after a week. I felt so horrible that I went in and saw my regular doctor, he discovered that I was anemic due to the blood loss from my surgery. I feel absolutley horrible, still. I have had 3 children with no pain medication, a broken femur, a gallbladder attack and none of those things come close to this misery. Maybe in a year I will think it was worth it but at this point I wish I would not have done it. I am a Nurse Practitioner so this is coming from someone who works in healthcare. I do not understand how anyone can say this is a simple surgery and I do not consider myself to be a whiner.

    Reply to this comment
    • Linda

      27. Jan, 2013

      Wow, Kristy, how awful. I so appreciate you taking the time to write this even though you must be in horrible pain. May I ask how old you are? Because my surgeon and I have talked about this surgery (underbite and lots of pain, but see a chiropractor who helps) for three years now, but I am in my 50′s and just trying to make this awful decision. I would have had it already by now. Just keep me in the loop and let me know how it is going. I sure hope you feel much much better and end up thinking it was worth it. But I get a very inflammatory response tojust about everything and i knew I would have a similar response that you speak of.
      I am also wondering if you had t o have your mouth wired shut. They tell me I have to but everything I read says you don’t anymore.
      prayers of healing coming your way, Linda

    • LIbby

      26. Aug, 2013

      I am having the surgery Dec 26, 2013, please share what to expect, I am getting scared. What have I done, I have had braces on for 4 months. Surgery Dec. then braces for 12 more months. I am 56 and scared!

  9. kevin

    05. Dec, 2012

    Can a patient with braces havebilateral eye surgery using and electrosurgical generator.

    Reply to this comment
  10. sam

    29. Dec, 2012

    I am 5 weeks post op, i had top jaw moved backwards and upwards and bottom jaw moved forward! I do not regret it atall, i have had a few hiccups, i had an infection around my mouth (which is still causeing a few problems) and i managed to pick up a virus in week 4!.. My drains stopped working in recovery room (which were painful) however ive had no pain relief since having the drains re suctioned on the day of the op!… I describe it as discomfort, swelling and numbness is a little irritating, im still unable to use my top lip (not sure if this will return or not) but i am very happy with the whole procedure . The whole recovery period is atleast 3 months, so still a long way to go.

    Reply to this comment
  11. Sara

    19. Jan, 2013

    i have reverse bite with lower jaw bigger than upper.I go for orthodontics treatment but after x-ray,impression and all other investigations my Dr. told me that orthodontics treatment is not possible you have to go for surgery
    i want my teeth to be set but i am afraid of surgery i cannot go through and it is expensive and i have heard that surgery is risky also.
    tell me is surgery in all cases is always 100% because i don’t want to become victim of any drawback

    Reply to this comment
  12. fakhrul

    21. Jan, 2013

    hii..thank for the very beneficial info. ..i would like to ask u on how to decide whether we need double surgery or not?

    Reply to this comment
    • marjom

      19. Feb, 2013

      hi all, i m a teenager frm india, i hav an underbite problem, my dentist said it cannot be cured with orthodontics. But i am waiting for a surgery at my 20s …i m called mango in my scul…bt i really lookd cute in my 13s with a normal face..and many used to admire me. Now i suffer ..i cannot eat properly or smile ..m ebmbarresed to smile. I am so scared of surgery and its consequences and my parents are not super rich. To get the surgery done…awh…i really want this done widout any complications aftr surgery. I m of 16 nw

    • Aaron

      13. Apr, 2013

      Hi marjom, I am 28 from USA. I also have an underbite problem, my dentist said I had to have jaw surgery to fix it, so I got preapproved on my adoptive fathers insurance, but by the time I was ready to have it they dropped me. My parents are not super rich to get the surgery done either…aww…i really want this done without any complications after surgery.too!

  13. Angela

    13. May, 2013

    I just had lower jaw surgery (Sagittal Split Osteotomy of the Mandible) on 5/1, about 2 weeks ago. It was and still is a highly uncomfortable recovery. I have a history of sensitivity to nausea related to being prone to motion sickness, yet despite the anti-nausea medications I still vomited 6 times the night and morning following surgery, mostly blood and bile. Once the blood was all out, I was OK. Pain wasn’t & isn’t too much of a problem, because of the amount of numbness I am experiencing in my lower lip and chin–I can’t feel anything. This is a known complication, and I am hoping that as the swelling goes down the nerve that is affected will slowly come back. For now, without sensation in my lower lip or chin, I don’t know if I am drooling until I see drips on the table or (worse) on my shirt.

    Because my jaws have rubber bands to keep them together, I can’t lick my lips so they are dry. Plan on using Vasoline or Chapstick multiple times a day. Conversations are fine in person but difficult on the phone. This is probably related to difficulties with projecting one’s voice with clenched teeth.

    I am able to drive but find the vibrations extremely uncomfortable due to the nerve damage. Thus, I’m not back to my normal schedule (which involves a lot of driving). SO, I don’t recommend having the surgery unless you absolutely HAVE to.

    In terms of food, I am still on pureed meals (smoothies, pureed soups). If you like raw oysters, you can eat those too (to celebrate Mother’s Day ;-).

    Thought I’d share my experience (so far), and good luck with your procedures!

    Reply to this comment
    • LIbby

      26. Aug, 2013

      How are you doing now? I am having the surgery Dec 26 and am getting scared. I am in sales and concerned about talking and appearance work in general.
      Pleas let me know or better yet phone me!
      404-606-2191
      Greatly appreciated, I am 56 yrs old!

  14. Jennifer

    23. Aug, 2013

    This is an excellent pamphlet about what to expect for the surgery. My friend just had this surgery, and I was looking for things I might be able to do to help her recovery, if anything. It’s nice to know that maybe I can encourage her to go for a walk with me or make her some mac ‘n cheese to supplement her Ensure might make her feel a little better, without worrying about interrupting or being counterproductive to the healing process. Thanks for posting this!

    Reply to this comment
  15. Mary

    25. Sep, 2013

    I am a 35 year old with an asymmetrical jaw. I have called several oral surgeons in the area and it seems like no one even wants to give me a consultation because they are scared that my insurance wont cover the surgery. I have BCBS and I think they might and I would like a chance but I cannot find a doctor to do it. Any help with this would be appreciated. I live in the New Orleans, LA area……

    Reply to this comment
  16. Jamila

    01. Dec, 2013

    Does medicaid cover double jaw surgery?? I was recently enrolled for medicaid coverage which will start in 2014… I have a severe underbite (class 3 mandibular malocclusion) and the only way that it can be corrected is with jaw surgery.

    Reply to this comment
  17. Talita

    08. Feb, 2014

    Hello, what is the procedure adopted in this picture that has this caption: “One of the most rewarding aspects of orthognathic surgery is improved self-esteem”?

    Thanks

    Reply to this comment
  18. kidist

    14. Apr, 2014

    I was doing a lot of researches about jaw surgery. I live in Canada and I also want to ask if the ohip covers for the surgery and if any one can write me the whole process expense. thank you.

    Reply to this comment
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  21. Chahat

    28. May, 2014

    My upper jaw teeth are so upward bcoz of that my upper lip also looks upward when i close my mouth i look like a monkey.,nd when i laugh my whole upper jaw teeth come outside from mouth what is that problem,nd my 21 is there any chance to correct it?

    Reply to this comment

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