Corrective Facial Surgery (Orthognathic Surgery)

1. Upper Jaw (Maxilla) And / Or Lower Jaw (Mandible) Surgery

Have you become aware that your teeth don’t mesh or bite together evenly like they should? Maybe you’ve been to see a Dentist about having your crooked teeth straightened and been told that your jaws are different sizes; perhaps you have developed jaw joint pain (on the side of your face in front of the ears) or difficulty and frustration with speaking clearly; are you challenged not being able to eat some foods without choking? All of these issues can result from an imbalance, mal-alignment or asymmetry of your facial bones and jaws. Orthodontic treatment (braces, invisalign) can straighten the teeth, but will not correct the underlying problem (upper and lower jaws of different sizes). Orthognathic surgery is needed to change the relationship between the lower jaw and the upper jaw and thus create an improved harmonious and more aesthetically pleasing facial appearance, in combination with restored jaw function and dental bite. A mandibular osteotomy is surgery to change the position of the lower jaw (which includes the position and size of the chin). A maxillary osteotomy is surgery to change the position of the top jaw (which includes the position and size of the base of the nose and cheek bones; there will also be subtle changes in the position and prominence of the tip of the nose).

2. Chin Repositioning Surgery (Genioplasty)

Sometimes the bone structure of the chin is either too small, too large or deviated (mal-aligned) away from the facial midline (asymmetric). In such cases, our Specialist Surgeons will perform a detailed (with the aid of computer aided virtual surgery) assessment of your facial features to arrive at the ideal position for your chin. Surgery to change the position of the chin is called a genioplasty; most often the procedure involves repositioning your actual chin prominence (part of the lower jaw); rarely a custom made prosthetic implant (high density plastic) may be used.

3. Combination Upper And / Or Lower Jaws + / – Chin Repositioning Surgery

Quite often, there is a need to combine procedures for repositioning of the jaws and chin in order to achieve the greatest benefits from surgery and more completely address functional and cosmetic issues. The decision is based on the individual’s facial shape and can be predicted with 3-D computerised virtual surgery based on Cat Scan data. Any planned combination of surgeries usually takes place during a single hospital admission; where the entire list of procedures is completed without the need for further Hospital admissions.

Temporo-Mandibular Joint (TMJ) Surgery

The majority of patients (95%) presenting with jaw joint pain will be effectively managed with conservative (non-surgical) management, continued for at least 3 months.

1. Conservative (non-surgical) Management of TMJ dysfunction

This treatment includes:

Joint rest – restricting mouth opening to within the range of movement that is comfortable (generally an opening distance of two of your own fingers; this is combined with a softened (pureed or semi-fluid) diet; it is very important not to continue to attempt to achieve full mouth opening whilst jaw pain is present.
Anti-inflammatory medications – take as prescribed for 10 days (whether you continue to experience joint pain or not).
Become aware as to whether you may be an habitual ‘jaw clencher’ or ‘tooth grinder’ as this habit will make the jaw pain worse; in these instances there may also be a role for either muscle relaxant medications or dental splints / bite guards.

A very small number of patients will progress to surgery for jaw joint problems; the presenting issues may include:

Chronic jaw joint pain that has not responded to a trial of conservative management for at least 3 – 6 months.
Jaw joints that have been destroyed by chronic disease (e.g. arthritis or tumours).
Jaw joints that have been operated on previously and may have developed pain or limited function again.
Jaw joints with restricted movement (open or closed lock, or an inability to open to the normal full range).

2. Jaw Joint Replacement Surgery

Jaw joint replacement surgery (TMJ arthroplasty) describes the complete removal and replacement of the jaw joint; currently this is achieved using a titanium and high density plastic (poly-ethylene) artificial joint. For many patients the jaw joint will be a custom made implant that is created using the latest 3-D planning and printing techniques, based on the individual’s own facial shape (utilizing CT scans). This procedure is very effective in relieving jaw joint pain and restoring function to the mouth and jaws.

Our Specialist Surgeons have performed many complete jaw joint replacement procedures and have extensive knowledge and expertise in the field; enabling them to guide patients through their available treatment options and procedures.

Facial Injury (Facial Trauma) Surgery

1. Cheek bone (Zygoma) + / – Eye Socket (Orbital) fractures

The cheekbone provides support for the eye and is a structural part of the eye socket (orbit). It is also linked to the side of the nose and the upper jaw (Maxilla). Fractures of this part of the face can therefore have effects on your vision (reduced, blurred or double vision) facial appearance (sunken mid face) and jaw function (limited mouth opening). Our Specialist Surgeons will consider the extent of the fractures and in order to decide both whether and what type of surgery is required.

2. Upper (Maxilla) and Lower (Mandibular) Jaw Fractures + / – Tooth (Dental) Fractures

Fractures to the upper (maxilla) and lower (mandible) jaws are commonly as a result of direct trauma (physical violence, sporting or motor vehicle accidents). As the upper and lower jaws also retain our teeth, fractures of these bones are usually associated with derangement of the dental bite (mal-occlusion); this issue is used to decide which patients need surgery for their jaw fractures. The surgery then re-establishes the dental bite and allows for the bone to heal in its pre-injury shape.

Damage to the teeth may result in further treatments becoming necessary for their ongoing health; depending on the situation you may need to have some teeth removed or repaired (if it is possible to do so). In the longer term, some of the teeth lost through such damage can be effectively replaced with dental implants.

3. Nose (Nasal bone) Fractures

Fractures to the nasal bones are common as a result of Trauma (physical violence or assault, sporting injuries). The nasal bones can be straightened (reduced) up to 2 weeks after the initial injury. Despite the nose being treated early, some patients will go on to develop difficulties with breathing through their nose or issues with the appearance of their nose after nasal bone fracture. Many of these issues will need to be addressed once the nose has completely healed (usually 6 – 12 months after the injury).

For some patients there will be a need for surgery to revise the appearance and improve the function of the nose (Septo-rhinoplasty).

Frequently Asked Questions

What does Orthognathic treatment involve?

The surgery commonly takes place once Orthodontic (braces, invisalign) treatment has repositioned the teeth in preparation for the surgery. In a smaller number of patients the surgery will take place either prior to Orthodontic treatment or without Orthodontic treatment at all. The planning for surgery is detailed and usually includes the production of custom surgical guides (stents) created with specialized software (based on the patient specific CT scan data) utilizing 3-D planning and printing techniques. The planning software provides vital information for procedure preparation – increases the accuracy of the procedure; reduces the risk of surgical complications; reduces the operating time; allows for minimally invasive surgery; provides the best chance of achieving optimal facial aesthetics and improved functional improvement. The procedure takes place in Hospital under a general anaesthetic (asleep); usually takes 2 – 6 hours of operating time. The operation is performed via incisions inside of the mouth (no visible scars in the skin). Patients will usually need to stay in Hospital for 2 – 3 days after surgery.
What should I expect after surgery?

You’re likely to experience some tightness over the mid to lower face, nose and neck; with discomfort and bruising around the base of the nose and cheeks extending into the upper part of the neck over the first few days; this will fade over the next two – four weeks. Ice packs (provided for you) and sleeping slightly upright for the first few days after surgery will speed the healing process. Commonly stitches in the wound will dissolve over 3 – 4 weeks after surgery.

You’ll be given scripted medications including antibiotics (to limit the risk of infection) and analgesics (pain relievers) to use at home.

Most patients can open their mouth (jaws are very rarely wired together) straight after the surgery. Mouth opening will be slightly restricted, but you will be able to talk, swallow and tolerate a soft diet.

It is important to re-establish a healthy eating pattern; a diet of easily consumed foods consisting of small amounts at regular intervals through the first few days is suggested. A pureed or semi-liquid diet (anything that can be slurped from a spoon or through a straw) is best for the first couple of days followed by soft foods that don’t need much chewing. As you feel more comfortable you can progress to more regular foods and meal times.
What does the facial trauma surgery involve?

Operations involving the trauma to the face (especially the cheek bones and eye sockets) are technically challenging; they carry a high risk of permanent complications; they take place within a very confined space. As such these procedures are best performed through the highly skilled hands of Specialist Surgeons. These procedures take place under a general anesthetic (asleep) and commonly involve the placement of small metal plates and screws to reposition and align the facial bone fractures. The aim of surgery is to restore facial form, function and appearance (simultaneously return to the pre-injury facial shape and function).

After a detailed assessment of the injuries (as guided by CT scan data and 3-D virtual models), surgery is planned to take place under general anaesthetic (asleep) in Hospital. A combination of small incisions inside the mouth, through the facial and neck skin and sometimes through the eyelids are needed to access the fractured bones to allow for re- alignment. Some fractures (eye socket fractures) will need more support in the form of bone grafts. Your Specialist Surgeon may also use titanium mesh, synthetic bone or your bone from other areas of your body to completely fix the fractures. Most patients spend one night in Hospital, to be released the next day.

Stitches used will usually dissolve completely in 3 – 4 weeks. Metal plates and screws are rarely noticeable (not visible or associated with other problems and routinely remain in place (these components are made from titanium so they won’t set off metal detectors in places such as the airport).
What should I expect during recovery from facial trauma surgery?

Initially the wounds are likely to be quite numb and hence pain-free for the first 12 – 24 hours. Swelling (and possibly bruising) will increase over the first 2 – 3 days before peaking.

You will have scripted pain relievers to use during this stage. Facial fractures rarely develop infection but you will be provided with antibiotics to further reduce the possibility.

There may be some swelling and bruising of the upper and mid face, including the eyelids; occasionally the white part of the eyes can appear red or bruised. With the use of ice packs (provided for you), compresses and maintaining an upright position in bed, swelling and bruising will fade within a couple of weeks.

Review appointments are necessary to ensure that healing progresses in an unhindered fashion. These appointments may extend over a period of 2 years; usually at 2 weeks, 3, 6, 12 and 24 months post procedure.