Coming Soon

Orthognathic means straight jaws

Why are straight jaws useful?  

 

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.

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. 

It depends. The envelope of discrepancy is an idea put forth by clinicians to visualize how far teeth can move with braces, with braces and tads/headgear, or with braces and surgery.  

Alternatives discussed include extraction of teeth (camouflage orthodontics) or utilization of temporary anchorage devices.  When considering alternative treatments, the functions of the core issue should be considered.

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. 

Coming Soon

Revision jaw surgery is not something people like to discuss.  The reality is that orthognathic and TMJ surgery are complex operations with long healing times.  Unfortunately, there are times where the final result warrants another surgery.  These are typically more complicated surgeries and so finding a provider who has extensive experience in these is difficult.  Dr. Bobek has treated more than 100 patients who needed a revision surgery.  This extensive experience has taught us a few things.  We have found success with comprehensively looking at the reasons why the previous operation did not end up as expected. There are many reasons for revision surgery and so reviewing all records and addressing the issues transparently are core principles to revision surgery.  We want to do everything we can to keep you away from more surgery!

What are the causes for revision surgery?

Revision is an umbrella term that includes many issues. Getting to the cause of the trouble is crucial. Many times the causes can overlap so let our team help you through the process.

Bones not healing after surgery is a complication seen in 2-4% of patients. In this situation, the area of the osteotomy has not healed with bone but with scar (fibrous) tissue. Symptoms include

    • Persistent facial swelling
    • Teeth fitting well with rubber bands but when they are taken off, the teeth really don’t fit
    • Loss of upper tooth show when you smile
    • Shifting of the bones on xrays (radiographs)

The jaw joint (TMJ) supports the lower jaw and can be stressed out during and recovering from jaw surgery.  Inflammation in the joint can cause the condyle (mandible portion of the TMJ) to shrink. This causes the chin to drift back or to the side and the bite (occlusion) to change.  Many people experience this without pain. This is a common cause of relapse more than a year after jaw surgery.  Frequently a discussion of TMJ replacement is had to correct this issue.

 This is the tendency for the body to return to its normal state.  With repositioning bones, the soft tissues (muscle, tendons, gingiva) pull the bones back causing the bone to shift during healing.  Another way to think about this is that your mouth is used to being used with the bones in the previous position. Until your swallowing, breathing and talking behaviors adapt, the bones can shift.  The stability of the bones is also due to the amount of movement and the direction of movement.  Maxilla down and maxilla wide are the most unstable movements. The next most unstable movements are mandible back, mandible asymmetry, maxilla forward+mandible back, and maxilla up+mandible forward. More stable movements are maxillary asymmetry correction, maxilla forward, any chin movement, mandible forward (short face), and finally maxilla up.  This can actually get more complicated from here so let us discuss the nuances with you!

Plates and screws placed during surgery can loosen or the bones they are attached to can break during healing.  This is typically due to the variation in plates and screws as well as the variation in everyones bone.  For instance, thinner or softer bone can have more difficulty holding fixation. 

Planning surgery with virtual 3d planning has removed many errors that were inherent to the process of planning jaw surgery.  If you had surgery prior to 2008, there is a liklihood that the need for revision is caused by those inaccuracies. 3d planning hasn’t entirely removed the possibility of error though as the outcome is still depended on CB/CT data, impressions/scans of teeth, human planning errors and head position. 

We find that the two main areas of dissatisfaction are more face change than expected and less face change than expected.  While there can be other reasons for esthetic dissatisfaction, for revision surgery to be considered, the problem with esthetics must be related to the bone position.  We think that improving communication with the patient during the 3d process makes this much better and taking as much time as needed for the plan helps minimize this outcome.  Our preferred technique with this group is superimposing the 3d bony images of the current state to the preoperative state and discussing ways to undo or augment this change. 

Very real limitations exist during surgery. Limited access through the mouth, bleeding, poor quality of bone, blood supply to tissues and managing unexpected fractures are all reasons why the final result is different than planned. 

This most commonly presents as persistent swelling and drainage.  Jaw surgery is in a classification of surgery called clean contaminated surgery. With this classification, there is an expected infection rate of around 10%. Luckily most of those are resolved with antibiotics. Some need hardware removal, cleaning out of the area (debridement) or more aggressive treatment.

It can be difficult not chewing after surgery or limiting bone movement after surgery.  While accidents do happen, chewing during recovery or grinding of the teeth can cause a nonunion or loss of fixation.  We find that bigger fixation or a period of the teeth wired shut can help in these situations.

While your healed result should be as strong as your jaws are now, during healing, that is not true. Life can happen after surgery and getting bumped by your child or dog or car door can result in shifting of the bones of the face.

How do I know if I need revision surgery?

Often times it is unclear if revision is needed based off of symptoms alone. Generally people notice their bite (occlusion) changing over time. The first symptoms are difficulty biting or chewing food.  TMJ pain or difficulty opening your mouth can be another symptom. A sensitive nonunion symptom is that your teeth fit well with rubber bands on but change dramatically when your teeth aren’t touching.  Loss of seeing upper teeth when you smile is another sensitive symptom of a maxillary nonunion.  Other symptoms can include face swelling, progressive face change, worsening numbness or prolonged postoperative orthodontics. 

Things that your surgeon, dentist or orthodontist might find include:

  • Changing appearance of radiograph
  • Loosening of hardware
  • Shifting of jawline
  • Worsening malocclusion
  • Great occlusion with elastics but malocclusion with no elastics
  • Anterior open bite
  • Irregular or smaller condylar heads
  • Difficulty with movement
  • Loss of incisal show

What are the options?

In many cases surgery should be considered but that isn’t always the case. A real discussion of the risks of making it better versus making it worse should be had.  Living with the result, while not ideal, may be a reasonable option with this in mind.  This is a conversation best had at your evaluation. 

People who have experienced facial dissatisfaction after jaw surgery may be battling facial dysmorphia.  This is when you become critical of your facial appearance.  Further surgery can make this worse so managing this with medication or therapy can be helpful. 

Condylar resorption isn’t always best managed with surgery and there are nonsurgical methods to help with this. Splints, restorative dentistry or medications prescribed through a rheumatologist may help. 

General dentistry or complex orthodontic interventions may help with more minor relapse issues.  An overall stable situation is needed for these interventions to help.  

Revision lower jaw (bsso), upper jaw (lefort) or chin (genioplasty) are different than the first surgery.  In the mandible, we typically design the osteotomy differently to better treat the outcome. Ramus osteotomies or alternative mandibular osteotomies may be used.  Maxillary osteotomies are frequently designed to minimize segmentation. Bone grafting is often different, with a consideration of using hip (anterior iliac crest) bone graft or even bone growing medicine (rhbmp-2).   Sometimes custom, printed hardware is designed and made to help optimize the location of the hardware. Lastly, 

Often times there is much more time spent discussing the intended goals, variable plans and risks. We find that revision patients frequently have two or three preoperative visits. This is time well spent to make sure everyone is comfortable with the plan

We have extensive information in our TMJ replacement section.  Please reference this for more details. Generally joint replacement is the right approach if severe condylar resorption is present and there is an open bite.  This is due to the high chance of further condylar resorption with a revision orthognathic surgery. There are times where unintended fractures of the condyle occurred during the first surgery and joint replacement can be a good option here as well. 

The most frequent second surgery after jaw surgery is hardware removal. We have found that removing hardware can help with pain and swelling at the surgical sites. This is a relatively simple procedure that is similar to wisdom teeth. If you have custom hardware or larger plates this can be a very invasive surgery so alternatives should be considered. 

Are there different risks?

Lower lip and chin numbness with lower jaw surgery risks are known. We think that the risk is a little higher with revision surgery because the nerve may have a second injury to recover from. Lingual (tongue) numbness can be more common in revision surgeries due to scar tissue and difficulties with fixation. Upper lip or palatal numbness can be increased as well

Bone and nerve healing can take longer after revision. This is due to scar tissue but also do to the natural aging process. Older people can take a bit longer to recover.  We will do everything we can to limit the risk of a secondary revision procedure.

Jaw surgery can change a lot. Addressing bony concerns may not address all of the concerns. Soft tissue issues, nerve injuries, and esthetic concerns can persist. Many people battle facial dysmorphia after going through all of this.  Being cautious with more surgery is always the best bet. 

Revision surgery can be a longer surgery than your original. That is due to the need to remove hardware and scar tissue encountered. Longer surgery can increase your risks for anesthesia and surgical complications. 

Top image: First surgery result (grey) superimposed to original state (red) Bottom image: Planned revision surgery (grey) superimposed to original state (red)
Superimposed revision result (white) over original state (blue)

Coming Soon

Orthognathic Surgery is the medical term for Jaw Surgery. It is a surgery to reposition the jaws to correct alignment. This realignment allows teeth to fit when misalignment cannot be solved by orthodontics alone.

We think it is reasonable to consider going through jaw surgery for a few reasons. Most frequently, the upper and lower teeth fit in a way that makes chewing and biting difficult. This match between the upper and lower teeth is referred to as your bite (occlusion.)   

If the occlusion is incorrect, you will hear the term malocclusion (bad bite.)  Common malocclusions are referred to as overbites, underbites, crossbites, and open bites.  These conditions are frequently related to the underlying structure of the bone being mismatched to the opposing bone.  Those two bones are the maxilla (upper jaw) and mandible (lower jaw).  When the lower jaw is too far forward (mandibular hyperplasia), or the upper jaw is too far back (maxillary hypoplasia), an underbite is present.  When the lower jaw is too far back (mandibular hypoplasia), or the upper jaw is too far forward (maxillary hyperplasia) there is an overbite.  the front teeth don’t touch (anterior open bite), the back teeth don’t touch (posterior open bite)

While malocclusions can lead to difficulty with biting and chewing, the cause of the malocclusion can cause other functional problems.  Small lower and upper jaws are associated with difficulty breathing during the day and night.  This is because there is less space for the tongue and soft palate to live.  You are good at compensating for this and the most common compensation is head position. People come in with neck pain and postural concerns because the are chronically adapting to their poor jaw position.

Underbites and open bites are associated with speech difficulty.  The tongue forms many sounds by touching the roof of the mouth behind the front teeth. If the front teeth are far away from the tongue, it can be difficult to speak.  Air escape can happen as well with front teeth that don’t touch. 

Jaw joint (TMJ) issues are complex but with severe malocclusions, people often find fatigue with chewing. This is because only a few teeth work to chew. Many chewing cycles can wear out the joint. 

Upper and lower jaws are mismatched for variable reasons. Common causes are TMJ arthritis, trauma, congenital issues, growth abnormalities, open mouth breathing, low muscle tone, jaw tumors or systemic issues. 

Jaw surgery is completed under general anesthesia as an outpatient surgery.  It is used to treat several conditions including a severe underbite or overbite, open bite, jaw or facial asymmetry, sleep apnea and others.

Typically, patients find themselves in our office after seeing an orthodontist. The orthodontist will make the recommendation based on your jaw alignment.  Surgery may be needed in addition to orthodontic treatment to correct your bite. They would refer you to discuss orthognathic surgery with a maxillofacial surgeon.

Your initial consult in our clinic will consist of one of our surgeons taking a history, doing an examination, reviewing your clinical photos and any available imaging. They will then discuss what is involved with jaw surgery and anticipated surgical intervention. You will also be shown a cartoon demonstration video of how jaw surgery is used to reposition the jaws. After this consult you return to your orthodontist to begin orthodontic treatment.

The traditional timeline for jaw surgery patients is to be in braces for a period of time, on average this is about 6-18 months to straighten and align the teeth prior to surgery. Then the orthodontist will tell the patient when they are close to being ready for surgery. It is then that you follow up in clinic for a recall visit. One of our maxillofacial surgeons will do another exam and we will take updated photos. The surgeon will then have a better idea of what surgical treatment they recommend. At this recall if you are ready for surgery you will meet with one of our care coordinators to schedule a surgery date.

You return to clinic to obtain presurgical records. These records include an updated CT scan and an optical scan of your teeth. These are used by the surgeons to complete your virtual surgical planning (VSP). This is a way to customize the surgery to each individual patient. At your preoperative visit we will discuss the process of surgery at the hospital, review your specific plan for surgery, and review instructions for recovery after surgery.

Surgery takes place at the hospital; you spend one night in the hospital after surgery and are discharged the following day. We see you in clinic for your post operative visits at 1, 3, and 6 weeks after surgery and then 6 months after surgery.

Jaw Surgery

Did you know?

Though only an oral surgeon can let you know if jaw surgery is right for you, there are some signs and symptoms that the procedure could be right for you:

  • Your lips do not meet in your natural bite
  • Your jaw protrudes noticeably forward
  • Your chin is receded backward
  • Your face seems unbalanced
  • You have open space between your upper and lower arches when your mouth is closed
  • You have breathing difficulties during sleep
  • You find yourself breathing primarily through your mouth
  • You have difficulty chewing and/or swallowing food
  • You have excessive wear on your teeth
  • You have ongoing jaw joint pain
  • You suffer with chronic headaches

You may be a candidate for corrective jaw surgery if you have a malocclusion (bad bite) that is caused by poorly aligned jaws. Only a complete consultation with an oral surgeon can help you determine whether jaw surgery is right for you.

At Seattle Jaw Surgery, you will be evaluated by Dr. Bobek to determine if surgery is right for you.  If you can avoid surgery he will be honest with you! If you could benefit from surgery, he will discuss the pros and cons.  

The decision to recommend surgery is based off of the individual. Functional troubles, clinical examination, radiographs (xrays), history, orthodontic exam and dental impressions are all considered when recommending for or against surgery. 

On the day of your operation, you’ll be placed under general anesthesia. An incision will be made on the inside of your mouth, through which your surgeon will reposition your jaws. Some jaw surgeries involve bone shaping, which may include shaving some bone away or grafting new bone into the jaw. A combination of plates, screws or wires may be used to hold the jaw in place before your incision is closed.

Please view our jaw surgery techniques on our videos page.

 

Yes. The initial healing phase is usually a few weeks long. During this time, you’ll be placed on a modified diet and instructed to avoid certain activities. It is important to take all medications as prescribed and to keep the incision site clean and free of debris. Your jaw may be swollen and sore for several days after surgery. Be sure to contact your doctor if you experience fever or any discomfort that worsens with time. Keep in mind that your jaw will continue to heal over the course of several months – a process that can take up to one year to complete.