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Jaw Surgery & Orthodontics

How specialties join forces to produce a beautiful smile

A Consultation with Dr. Jon D. Holmes

Dear Doctor,
The orthodontist who was going to straighten my daughter's teeth said she had a jaw alignment problem and needs to consult with an oral surgeon. Can you please explain why?

Before After
This person has a skeletal discrepancy with a larger lower jaw that prevents correct tooth alignment. In addition, she has an asymmetry with her lower jaw shifted to the left. Notice the dramatic change to the facial profile after orthognathic surgery, plastic surgery and orthodontic tooth movement has been completed.
Before After
A closer inspection shows how her lower teeth are even, but slightly in front and to the left of the upper teeth. After treatment, notice the correct alignment of the upper and lower teeth and jaws.
Photos provided by Dr. Jon D. Holmes

Dear Rhonda,
Simply put, the major job of an orthodontist, a specialist in diagnosing and treating malocclusions (mal-bad, occlusion-bite), is to straighten teeth into better alignment and function for long-term dental and oral health. Orthodontists will commonly refer to an oral and maxillofacial surgeon when a team approach is required to treat a particular person's orthodontic problem.

Think of it this way. The jaws are arch shaped and in fact are referred to professionally as dental arches. One arch, the lower or mandible, essentially is supposed to fit inside the other, the upper arch or maxilla. Think of your dental aches as horseshoe shaped and you'll get a better picture. Before the teeth can line up — meaning bite together in proper alignment and position — the jaws (two horse shoes) must be in correct position and alignment. If you think of this in 3D (three dimensions), there can be vertical, horizontal, and back to front alignment problems. Also, some people have asymmetries, which occur when one side of the face appears different from the other. While all people have some differences in the right and left sides of the their face, substantial differences can contribute to bite problems as well.

Sometimes when the discrepancies in jaw size and position are minor, an acceptable aesthetic and functional result can be achieved by just moving the teeth. However, when the jaws are too far off from each other, surgery is required. An example is when the orthodontic problem is mostly a skeletal issue not allowing one jaw to line up well with the opposing jaw.

X-ray
The pre-surgical x-ray showing the relationship of the upper and lower jaws and the facial profile. Note the relationship of the upper lip and lower chin.
X-ray
After orthognathic surgery, an x-ray allows comparison of the relationship between the upper and lower jaw and the resulting improvement in the facial profile.
Orthodontics performed by Dr. David Sarver

Perhaps one of the most unique and important surgical procedures an oral and maxillofacial surgeon does is what is commonly referred to as orthognathic surgery (“ortho” – straight or erect; “gnathos” – jaw). This surgery corrects a wide range of minor and major skeletal and dental irregularities, including the misalignment of jaws and teeth, which, in turn, can improve chewing, speaking, and breathing. While the person's appearance may be dramatically enhanced as a result of this surgery, orthognathic surgery is performed to correct functional problems.

Some of the other conditions that may require corrective jaw surgery include: difficulty chewing or biting food, difficulty swallowing, chronic jaw or jaw joint (TMD; Temporomandibular Joint Disorder) pain and headache, excessive wear of the teeth, open bite (space between the upper and lower teeth when the mouth is closed), unbalanced facial appearance from the front or side, facial injury or birth defects, receding chin or protruding jaw, inability to make the lips meet without straining, chronic mouth breathing and dry mouth, and sleep apnea (breathing problems when sleeping that include snoring).

Many of these problems have an orthodontic component and involve teamwork between a general dentist, an orthodontist and an oral surgeon. Often the orthodontist will “set-up” the case — that is get the teeth aligned first. This sets the stage for the surgeon to align the jaws surgically so that they can be guided and retained into their new position so that the teeth will bite or mesh perfectly. As you might think, this requires careful assessment, diagnosis, and pre-planning.

As you can see orthognathic surgery produces major benefits, but there could also be some limitations and complications that require a detailed discussion with the oral and maxillofacial surgeon depending upon the specific problems involved. These jaw surgeries are not inconsequential and need careful consideration of all the possible risks, benefits, and alternative treatment options.

Watch for a future feature article on this life-changing topic.



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