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.
