SEATTLE JAW SURGERY

Instagram Facebook Google
Make a Payment

Customization of hardware has always been a part of jaw surgery.  We bend each plate and adapt each screw to your individualized anatomy.  For TMJ surgery, replacement devices are fabricated by hand to fit your individual anatomy.  These are all invaluable and have been a mainstay of contemporary orthognathic surgery

 Over the last 5-10 years, hardware companies have been promoting 3d printed hardware.  This type of hardware can be a very useful tool in complicated surgical situations such as cancer or trauma reconstruction.  Dr. Bobek uses this type of hardware during jaw surgery with some inverted L osteotomies, some revision surgeries, and with some inferior positioning of the maxilla surgeries.   

 

The trouble with the 3d printed hardware is cost. Jaw surgery can be very expensive and increasing the absolute cost of hardware by 5, 10, or even 15 thousand dollars seems wasteful for routine surgeries.  American healthcare is plagued with cost overruns and it is our belief that the large hardware companies are marketing these devices to make more money.  We value transparency in cost and being good stewards with all of our resources. 

There has been no evidence that 3d printed hardware improves surgical outcomes or decreases surgical time for routine orthognathic surgery.   Again, it is very useful in complicated scenarios, but we just cannot justify the cost for the vast majority of jaw surgeries.  At Seattle Jaw Surgery, we will consider your situation from all aspects – quality, cost, risk and benefit.  Come see us to see which kind of hardware is best for you!

Coming Soon

Coming Soon

At Seattle Jaw Surgery, we uniquely involve patients in the process of their surgical planning.  Each person now sits down with Dr. Bobek to “fly through” and adjust the surgical plan.  He involves you in your preferences for surgery, customizing the amounts of movement, location of bony cuts and accounting for the particular risks in your anatomy.  We find that patients learn much more from seeing and interacting with the actual 3 dimensional planned movements. Unfortunately, most centers give you pdf images of what they think is right.  We want you involved! 

Here is an example of how planning was used to correct the way the teeth fit while also narrowing the lower jaw. This improved the jawline esthetic while improving the function of the teeth. 

At Seattle Jaw Surgery, we are on the cutting edge of planning.  We use the latest technology for digital impressions of teeth, low dose, three dimensional CBCT imaging of the face and versatile surgical planning software.  This allows for a comfortable patient experience while understanding what will be happening in surgery.  Our all digital workflow allows for easy coordination with orthodontists and coordination of care for patients living far away from Seattle. 

 

Jaw surgery planning has not always been this way!   Traditional surgical planning involved dental impressions, clinical examination, 2 dimensional xrays and face bows.  It is amazing that the surgeons at the time did such an excellent job with such limited data.  Dr. Bobek has the unique experience of training in the traditional surgical planning while also being involved in the advancement of virtual surgical planning. 

Virtual surgical planning shines in complex situations. Since jaw surgery is performed through very small incisions, the ability to visualize complex movements and trouble shoot difficult situations makes the surgical teams work much easier.  

Here, more than 4cm chin advancement is planned with TMJ replacement devices, a segmental upper jaw surgery, and a subapical osteotomy.  

Unfortunately, virtual planning isn’t perfectly accurate. Errors commonly are noticed in midlines of the upper and lower teeth, TMJ position, the way the teeth fit, and asymmetry.  Our team has planned thousands of cases and we are always on the lookout for better ways to do things!

A good example of how virtual planning can be inaccurate is in head position. Here is an example of how much head position alters the final plan. 

Coming Soon

Coming Soon

Joint injections or Arthrocentesis is a minimally invasive procedure where one or two needles are inserted into the jaw joint (TMJ) and fluid is injected into the joint. This washes away inflammatory byproducts and lubricate the joint. We use saline, steroid, blood or PRF to inject into the space. This is a good option for inflammatory arthritis flare ups and acute closed lock. 

We also use injection therapy to inject muscles (botox), tendons (steroids), and nerves (local anesthesia.) These can be very helpful with TMJ dysfunction symptoms. 

seattle jaw surgery man woman patients

Arthrocentesis is most useful in flareups of joint arthritis. There are four common situations:

  1. Acute closed lock – this happens when your disc (the thing that pops in the jaw) to get stuck, limiting your ability to open your mouth. Often times this gets better with rest, stretching but if after 2 weeks it has not improved, arthrocentesis is very helpful.
  2. Inflammatory arthritis flareup – people with juvenile idiopathic, rheumatoid, or psoriatic arthritis can have flare ups that respond very well to arthrocentesis and steroid injection.
  3. Chronic TMD flareups – A derangement of the disc can be a lifelong problem and like other joints, wear and tear arthritis (osteoarthritis) can develop.  To help prolong more invasive surgery and to treat persistent episodes of pain, arthrocentesis can help.  We use steroid, prf or hyalagan to inject these joints. 
  4.  Chronic dislocation – Some people have repeated visits to the emergency room because their jaw gets stuck open. If this happens repeatedly, we offer two options – blood injections or eminectomy.  Blood injections are done after arthrocentesis and are the more minimally invasive option. 

Absolutely.  The most common TMJ disorders are best managed without surgery.  Joint flare ups can be successfully managed with jaw rest, medication and time.  More than 95% of people with TMJ symptoms improve without any surgery.  If your symptoms continue despite conservative measures, we can see you for an evaluation. 

Often when considering surgery, we obtain a MRI to evaluate the joint in more detail to offer you surgical solutions based on your anatomy.  With arthrocentesis, a MRI isn’t necessary. The procedure is rather generic and improves most joint flare ups independent of the joint anatomy.   Arthrocentesis is a great temporary solution to temporary joint conditions. 

There are multiple options that we offer:

  1. Saline – rinsing the joint with sterile salt water allows the inflammation within the joint to be washed out. This allows for a reset of the joint contents and an improvement in pain symptoms. 
  2. Steroid – Corticosteroids can reduce inflammation in the joint and help with pain. With inflammatory arthritis, steroids can be very helpful. They may even soften scar tissue within the joint to allow your joint to be more mobile. The down side is that they can change the bone in unfavorable ways with repeated injections. 
  3. Platelet rich fibrin (PRF) – This is a portion of your own blood that has concentrated growth factors to help the joint repair.  Your blood is spun in a centrifuge to split up the components.  Platelet rich plasma (PRP) has been used in the past as it contains growth factors, fibrin glue and platelets. PRF has become more popular because it has less processing and easier to use. 
  4. Blood – Injecting your blood into your jaw joint may sound crude but it is helpful for chronic dislocation of the TMJ.  The idea is to form some scar within the joint to limit mobility and often times two or three rounds of blood injections are needed to help with chronic dislocation. 
  5.  Hyaluronic acid – HA is sometimes used to provide lubrication to the joint.  For some people, they want us to use this and we can help!

Risks with arthrocentesis are very low. The most common risk is that your joint symptoms are either no better or minimally better with the procedure. Many people experience temporary eye lid weakness from the local anesthesia given during surgery. This resolves in a few hours.  Long term facial weakness, facial numbness, change in the way the teeth fit (occlusion), infection, or bleeding are all very rare (<1%.)  

This procedure is done under IV sedation in the clinic. The surgery is relatively short with most people being here for 45-60 minutes (10-15 minutes for procedure).  We recommend a soft diet and immediate movement of the jaw.  Most people have weakness in their eyebrow after this surgery. This is from the numbing medication There is swelling in the area that gets better in 1-2 days. 

We inject other things than joints to help TMJ disorders.  They are: muscles, nerves and tendons.

Muscle Injections

Generally muscles that have grown too large (hypertrophy) from overuse or are in spasm can benefit from muscle therapy.  We favor nonsurgical approaches such as massage, physical therapy and rest.  If the muscles are so large that you cannot break the cycle of dysfunction, or if conservative approaches haven’t helped, muscle injections can.  Botox is by far the most common medication we use. Botox partially paralyzes the muscle for about 6-8 weeks.  During that time it weakens (atrophies.)  We inject botox in the masseter, temporalis, lateral pterygoid and sometimes the mentalis. This can be very helpful for muscle pain but it also decreases the forces on your joints.   Having us inject the muscles help minimize leakage of botox to adjacent muscles and help dial in the appropriate dose.  

Before and after botox to the masseters. Notice the decrease in bulk of muscle and change in face shape. 

Tendon Injections

We find that temporalis tendonitis is common in people with TMJ flareups. The temporalis is a big muscle on the side of your head and it attaches to the jaw via at a point called the coronoid process. It looks like a sharks dorsal fin on either side of the lower jaw.  

Tendonitis of the temporalis tendon shows up as pain in your cheek towards the back of your teeth.  Usually there is a very tender spot if you feel the inside of your cheek and reach as far back as you can. That is the temporalis tendon.  This can improve with rest, massage, ice and stretching. 

A common situation of tendonitis is repeat local anesthesia injections at the dentist. People sometimes find that they can’t open their mouths after dental treatment and the most common cause is temporalis tendonitis. 

A very simple thing is for us to inject the area with a steroid and local anesthesia. If this works and the pain returns, we can discuss a tendon release, but for many people one round of injections is all that is needed. 

 

Steroid injection into the temporalis tendon.

The coronoid process – where the temporalis tendon attaches.  A tendon release is called a coronoidectomy, a straightforward procedure that dramatically helps with mouth opening in people with contracture of the tendon. 

Nerve injections

Lastly, local anesthesia injections to nerves can help temporarily alleviate pain. Nerve injections can also help with diagnosing the problem. We use these as adjuncts to the overall picture. 

Open joint surgery is more of a descriptive term for access of the TMJ rather than a specific procedure. An incision is made by the ear and Dr. Bobek can access the joint to address a number of issues. It is an outpatient surgery offered to people who cannot be improved with less invasive techniques (injection or arthroscopy) and don’t want more invasive techniques (tmj replacement.) 

Here are common questions in regards to this procedure

Much like other TMJ surgeries, a clinical exam and MRI are useful for determining if open surgery is right for you.  For most people with a painful joint and limited function, nonsurgical techniques are still best. But if you are not improving, have severe arthritis, or have other noninternal derangement problems, open joint surgery might be right for you. 

There are more groups of people who benefit from open surgery than arthroscopy. Here are the clinical situations where open joint surgery makes sense. 

This is a procedure to reapproximate the disc between the condyle and the fossa. Typically used for moderate to severe internal derangement, this allows for the disc to be anchored to the condyle.  The video at the start of this page shows this surgery.  Metal anchors (mitek) are not used now as they make future MRI evaluation difficult. Dr. Bobek utilizes a juggerknot suture anchor to better anchor the disc. 

This is a more typical procedure for TMJ arthritis. Much like a meniscus removal from a knee, the TMJ disc is removed to allow for better mobility in situations with advanced arthritis. A common alternative is TMJ replacement.   With removal of the disc, the condyle can move more freely along the skull (fossa), improving mouth opening and pain. Bone spurs can be smoothed and the joint recontoured.  Dr. Bobek most frequently uses abdominal fat to graft the space left by removal of the disc. This is to reduce the risk of ankylosis, or fusion of the joint. Other materials used include dermis or temporalis muscle. These are not preferred at Seattle Jaw surgery but are used in some unusual situations.

The eminence, is the prominence of the skull that the jaw slides down when you open your mouth widely.  Some peoples jaw gets trapped in front of the eminence, a situation called joint dislocation.  Frequently people need to go to the emergency room or an emergency dentist to relocate the jaw back behind the eminence.  TMJ dislocation can be a chronic condition that is best treated with the removal of the eminence, a procedure called eminectomy.   This is a reduction or removal of the eminence so that the jaw (condyle) doesn’t get trapped and the jaw doesn’t get stuck dislocated.  A more conservative alternative to this are blood injections. 

Sometimes there are growth abnormalities in the condylar head. In younger people, that condition is known as condylar hyperplasia. With condylar hyperplasia, the jaw grows very asymmetrically after the persons growth is otherwise complete. In older people, it is known as an osteochondroma.  Treatment of active condylar hyperplasia and some osteochondromas is with removal of part of the condyle. This procedure is known as a condyletomy.  Partial removal of the condyle allows for removal of the growth center and improvement in the condyle contours. The disc is secured to the reduced condyle with a juggerknot. This procedure is most commonly done with orthognathic surgery to maintain the way the teeth fit.

Most benign joint tumors are most easily accessed via an open joint surgery. Removal of synovial chondromatosis (joint mice), osteochondromas, pigmented villonodular synovitis, chondromas, osteomas, or even joint cysts can be done via an open approach. These are rare lesions but are safely removed via this surgery. 

Jaw fractures can happen anywhere from the chin to the jaw joint. Jaw joint fractures are known as condylar or subcondylar fractures.  Jaw joint fractures can be treated with your teeth wired shut or with surgery to align the broken bone and place plates and screws to hold the bone together.  Given the unique anatomy of the TMJ, some fractures cause the condyle to be pulled out of the socket, a condition called a fracture dislocation.  These are best managed with surgery and open joint surgery allows the disc to be appropriately positioned between the condyle and skull (fossa).  Unfortunately, some people with this injury are treated with wiring of the teeth shut (closed reduction.)  We use the open approach to the TMJ to help those people with either joint replacement or a condylar osteotomy.  

This is a surgery that is largely the same as removal of the disc and fat grafting.  The difference is that a gap arthroplasty is seen as an alternative to joint replacement for fibrous or bony ankylosis. This can be useful in patients without teeth or who cannot receive a joint replacement. 

TMJ infections, while rare, do happen. These are typically surgical situations due to the proximity of the joint to the brain. Sometimes infections can be managed arthroscopically but not always. With TMJ replacement devices, managing early infections is done with a DAIR protocol. Extra bone that grows over the TMJ device (heterotopic bone) can also be removed via open TMJ surgery. 

This is an unusual problem caused by a patent Foramen Tympanicum (Huschke.) Approximately 1-3% of all people have this but a much smaller percent of people have problems with it. The classic symptom is that your hearing is muffled when you bite into food. Typically diagnosed by ENT (ear nose and throat) doctors, this problem can be repaired with a simple cartilage graft. 

A hole in the right disc as seen from the side.

Absolutely.  Like all other TMJ surgeries, you should try to get better with more conservative approaches. Common ones include jaw rest, medication, physical therapy, or even splint therapy.   In terms of surgery, a good alternative to arthroscopy is injection therapy. 

The most common risk with an open TMJ arthroplasty is scarring. Scarring can limit motion and cause pain.  Pain or limitation in movement following surgery is always a risk so we have you limit chewing and liberalize movement following this surgery.  Physical therapy is very important in recovery.  Even with good physical therapy the scarring can be such that more surgery or injections are needed.  

Another risk with this surgery is that the way your teeth fit can change. If it is one sided surgery where the disc is removed or a tumor is removed, the teeth on the side of surgery tend to hit first.  If the disc is repositioned the other side of the mouths teeth hit first.  Most people manage this with general dentistry (adding to or trimming teeth) or braces. Rarely, the way the teeth fit is bad enough to discuss jaw surgery. 

You do need physical therapy. Physical therapy helps keep your joint moving after the scar is removed or the capsule is released.  

Face weakness, change in occlusion, and face numbness are other more rare risks. 

TMJ disorders are seldom “fixed”.  Unfortunately they  flare up from time to time. Open TMJ arthroplasty is a surgical technique to help you adapt to the different anatomy in the joint and manage longer term flare ups. The surgery increases the space for your jaw to move. All of these can help with pain and movement of the joint, but they do not “fix” the joint.  

Picture of an ear canal with the mouth open (left) and closed (right). Herniation of the TMJ into the ear canal is seen as the pink dome on the right. 

Coming Soon

 

Maxillomandibular advancement (MMA)

Sleep apnea is a very common chronic disease. Estimates are as high as 1/3 of the adult population has sleep apnea and many are untreated or undertreated.  The most common way sleep apnea is managed is through PAP therapy. This involves wearing a mask at night every night from now on.  For many people, particularly young people, PAP therapy is not a reasonable option. 

The surgery with the highest rate of success is a tracheotomy. This is a hole in your neck, which again, for many people is unreasonable. The next best is MMA.  This is jaw surgery to open the upper airway.  The idea of this surgery is to move both the upper and lower jaws to create as much space as possible for you to breathe.  This surgery has a success rate of 86% for people with moderate to severe OSA.  While moving the lower face may sound more invasive than a tracheotomy, it is the same surgery we use to help orthodontists treat people whose teeth don’t fit well.  This surgery is used in cosmetic surgery for jawline enhancement and gender affirmation.  MMA is just upper and lower jaw surgery with the goal of creating space to breathe.

MMA is carried out through a lefort osteotomy and a mandibular osteotomy (most commonly a BSSO).  Here are common questions we hear.

The best literature as the surgical success rate at 86% and the cure rate at 43%. These terms have meanings as success is a 50% reduction in AHI and reducing the AHI less than 15. Cure is AHI less than 5.  These numbers are in people with moderate to severe sleep apnea.  Success and cure are seen more often in younger people, women, and in people with smaller jaws.  Other sleep surgeries have success rates of 10-50% with cure rates much lower. 

One of the big advantages of MMA over nonsurgical approaches to OSA is that you don’t have to do anything to breathe better. No more masks, appliances or positioning devices.  

Sleep apnea is more complicated than just the bony anatomy of the face. Sleep physiology – specifically loop gain and arousal threshold – is different in each of us. Unfavorable physiology can lead to no to minimal response to surgery.  Another common cause of residual apnea after MMA is that other things cause apnea. Weight loss is often helpful as is establishing nasal breathing.  We have also seen people with long palates, floppy epiglottis, or tonsils that are still in the way following MMA. We know ear nose and throat docs to refer you to.  

The biggest risk is that you still have sleep apnea after MMA.  This was addressed before. The next most common risk is numbness. Surgery is through bones and the feeling of your teeth, gums and maybe lip and chin can be different after surgery. Most people have temporary numbness while some have permanent sensory changes. 

MMA changes your lower facial structure. A risk is that this change is unfavorable. Widening of the base of the nose is a common unfavorable change. We customize all of our plans to you to minimize unfavorable face change.

Need for more surgery is another problem. No one wants one surgery let alone two! Luckily, if a second surgery is needed, it is to remove some of the plates and screws. These are removed due to infection or pain.  Other times the bones do not set right, causing either the bones to heal in an unfavorable position or not heal at all. This can lead to a revision surgery.  

Other risks like infection and bleeding are manageable. This is a safe surgery but there are risks. We look forward to discussing them in more detail with you. 

MMA surgery takes 2-3 hours. Many times, this is outpatient surgery but other times you spend a night in the hospital.

A misconception of MMA is that the recovery will be terrible. It is a long recovery but most people need 1-2 weeks off from work. Your teeth are not wired shut following surgery.  Unfortunately, we do not want you using your teeth to eat after surgery. For 6 weeks you use a blender or fork and knife to do the chewing for you. This is to allow the upper and lower jaws to heal. Pain is typically not the biggest issue after surgery.  Most people find nasal and sinus congestion to be difficult. This improves after a week or two.  Pain medication is prescribed for 7-10 days after surgery to help with the discomfort. 

Many people find that facial swelling takes 2 months to go away completely. The more impressive swelling lasts for 1-2 weeks.  We don’t want you working out or lifting heavy things so many people find recovery to be boring. This can take a toll on your mental health so we want you to be as prepared as you can be for surgery. 

We typically meet with people three or four times before MMA surgery. During those visits, we discuss the recovery process in detail.  We have videos to learn more about it now if you would like! 

Sometimes braces (orthodontics) can help set you up for a better final surgical outcome. Other times braces are needed to correct any changes in the way the teeth fit following surgery. 

The best candidates for MMA are people with small jaws. Advancing those people with surgery often has favorable benefits on facial esthetics. Chin projection, improved jaw line, better facial balance, and improved lip support are all things that people notice.  

We often find that people notice the increase in upper airway size during the day. This makes breathing at rest or with exercise easier.  While these reports are anecdotal, it makes sense that breathing takes less effort with more space.  

If your teeth don’t fit ideally, MMA can improve this too.  Underbites, overbites, cross bites, open bites can all improve dramatically with MMA.

The last benefit is head position. People with upper airway restriction have a chin up head forward head posture. This causes tension in the posterior neck. MMA improves posture through pulling on the anterior neck musculature and opening the upper airway. 

Many insurances provide coverage for MMA to treat sleep apnea.  Here are common criteria that insurance companies want us to show in order for them to provide coverage.  

  1. moderate to severe OSA
  2. intolerance of pap therapy (6 month trial)
  3. reasons why other treatments won’t work

Contemporary MMA uses various surgical adjuncts to improve the final outcome.    

The animated surgical simulation prior to this section is a surgery that Dr. Bobek refers to as MMAW.  The upper and lower jaws are advanced and widened at the same time.  He is a pioneer in this surgery as the complexity is high.  Widening the arches at the time of MMA or as a first stage surgery (midline distraction) is thought to decrease the risk of persistent sleep apnea after MMA. Widening of the upper and lower arches gives more tongue space and nasal breathing. It does change the face more in that the jawline becomes wider.  We find this procedure to be useful in people comfortable with a more traditionally masculine jawline. 

Counterclockwise rotation  refers to an increase in the occlusal plane’s pitch when viewing the head from the right profile.  This allows for a better opening of the upper airway and for improved facial aesthetics. MMA can be associated with negative esthetics in some people.  The classic negative face change is too much fullness under the nose giving a simian appearance. Counterclockwise rotation of the upper and lower jaws helps minimize face change. 

While surgery on your chin may not seem helpful for breathing, the tongue attaches to the inner aspect of your chin. This area is referred to as the genial tubercles. Moving the genial tubercles forward pulls the base of the tongue forward. This surgery is known as Genial Tubercle Advancement (GTA).  Dr. Bobek performs this along with a traditional genioplasty.  By doing a genioplasty, the genial tubercles can be better visualized and there is no need to twist the tubercles as classically described in GTA.  Chin esthetics can be addressed at the same time – whether it is to minimize the change with MMA or it is to maximize the change. 

Often, nasal breathing is much improved with MMA. This has to do with the increased nasal airway space associated with this procedure. Additional things can be done at the time of MMA including a septoplasty or turbinate reduction. The floor of the nose (alar base) is often widened during MMA to help with nasal breathing.

Airway changes typical of MMA

Here are typical changes seen with MMA. These are 3 dimensional pictures of the upper airway before and after surgery.  First pictures are from the side and the second are from the front. A doubling in total airway space and tripling in minimum area is to be expected.  Here are some superimposed airway changes.  The little black circle is before surgery and the larger circle is after surgery.  The lower images are a little different way to visualize things. 

seattle jaw surgery logo
Instagram Facebook