A. Treatment Aims
The aim of the combined treatment is to restore structure and function, that is, stable and aesthetic. To this aim, the orthodontist uses braces to align the teeth to their jaws. Once this has been achieved, surgery is used to align the jaws and other facial components as is necessary. To achieve the treatment aims, a treatment plan is devised by the orthodontist and the oral and maxillofacial surgeon who will then co-ordinate the treatment plan with your family dentist and medical practitioner. On occasions, other health care specialists may be involved. Your treatment plan is based on your concept of the problem, the clinical assessment and the radiographic analysis.
The advantages and disadvantages of the treatment plan with any possible alternatives, as well as the duration of each stage will be explained to you. No treatment will commence until you have a full understanding of what is involved.
B. Treatment and the Sequence
There are four stages of treatment
- Treatment before orthodontics
- Orthodontics before surgery
- Surgical treatment
- Treatment after surgery
This overall combined treatment takes an average of about 12-18 months to complete.
1. Treatment before orthodontics
This is usually carried out when the orthodontic treatment is about to be commenced. It could involve the removal of teeth, the exposure of teeth or soft tissue surgery. You will also definitely see your family dentist for preventative management and possibly fillings, whichever the case, you will be informed of what is required before braces are placed on your teeth.
2. Orthodontics before surgery
Orthodontic treatment means you will have to wear braces on your teeth for about 6-12 months before the surgery. The braces are used for the necessary alignment of the teeth as a preparation for jaw surgery. Further more, the braces are essential during and after surgery to help keep the teeth and jaws aligned.
3. Surgical Treatment
a. PREPARATORY PHASE
Once the teeth are orthodontically aligned, the precise and final surgical treatment plan is made based upon further clinical and radiographic reassessment. Then the braces are slightly modified to aid the surgery. After this, impressions will be taken for the construction of splints, which will position the jaws into the predetermined position. The detailed surgical treatment will be explained to you, the duration of the hospital stay, and the stages of the recovery period. This will provide you with another opportunity to ask further questions and to obtain additional understanding of the surgical treatment so you will be able to give informed and signed consent.
b. HOSPITAL PHASE
The admission to the hospital and the anaesthetic assessment is the same as for any other surgery. Usually you are admitted to the hospital the day before the operation. The first night after the operation is spent in intensive nursing, after this, you are returned to the wards for 1-2 days approximately.
4. Treatment after surgery
During this healing phase you will wear elastics on the braces for 3 months. Also during this phase the orthodontist will further adjust your teeth for about 3-6 months to align them to the new jaw position from the surgery. Once the braces are removed, you will wear a retainer for at least 12 months.
Your visits to the Oral and Maxillofacial Surgeon has the following sequence upon leaving the hospital; You will be seen weekly for 6 weeks and radiographic assessment will also be carried out on the first week and then in the 6th week after surgery. After which you will be assessed clinically and radiographically at 3 months, 6 months and thereafter yearly. The reason for this is to assess the healing and the stability of the operation. It should be noted that these are separate from your normal visits to your family dentist and your orthodontist.
C. After Affects from the Surgery
1. Psychological Aspects
It is not unusual to become depressed after any surgery but especially so with facial surgery. The duration and intensity varies and usually passes as you recover from the surgery and your condition improves.
Pain is usually not a major factor with most patients that have had this type of operation. Obviously there is going to be considerable variation in pain response with patients and it depends on their perception and psychological state at the time of the operation.
Facial swelling reaches a peak within 36-48 hours after surgery. The swelling does not begin to decrease until about 1 week after surgery & will take 6-8 weeks before it has significantly disappeared.
4. Jaw Stabilisation
Recent advances in jaw surgery means that 99.5% of the types of operations do not require the jaws to be wired together. Instead, only light elastic bands are used to stabilise the jaws. This means that you can speak, swallow and drink soon after the operation with minimal problems. While chewing, has to be gradually built up over a period of time.
If your jaws have to be wired together, this will last for 4 weeks with an operation on the upper jaw, and 6 weeks if the lower or both jaws were operated on. This means that your speech could be more difficult, especially with telephone conversations. However with time, people adjust to drinking and taking in food with this situation.
Most of this type of surgery is carried out inside the mouth, which means no obvious scars. Although in some cases where the lower jaw is being operated on very small incisions may be placed on both sides of the neck.
6. Soft tissue response to the surgery
This usually takes a significant period of time and varies markedly between individuals especially in the short term. The first 80% of return to the new structure and function occur within 1 month. The remaining 20% seem to be age related. In this way it is roughly 6 months and 1 extra month for each decade. For example, 9 months after surgery is required for a 30 year old person.
7. Nerve injury
It is common to have loss of sensation with orthognathic surgery especially when it involves the lower jaw. This means there is normal movement of the lips but there is a loss of lip awareness. Obviously, no one will realise you do not have feeling in the lips except for yourself. The return to sensation is a gradual process and is patchy but it is usually self-limiting. For example, in the young it can take 9 months and for the older patients it will take longer. Unfortunately a small percentage of people never have a return of sensation in areas of their lips.