Oral-&-Maxillofacial-Surger

A young lady came to our clinic complaint that she was not happy about her face because of her lower jaw was too long. On top of that, her teeth weren’t aligned well. After examination and a few x-ray, we found that she had a few problems:

  • Her lower jaw was long as compared to her cranial base
  • Her upper jaw was shorter in relation to her cranial base
  • Her cheek looked more flatten
  • She can’t close her lips as her lower jaw as too forward
  • Her lower teeth were very far forward as compared to her upper teeth
  • Her dental mid-line was not coincide with her face mid-line
  • She was biting only on a few teeth when chewing

Facial view

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Front

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Oblique

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Side

Radiography view

OPG-Pre-ortho [1600x1200]

OPG

Lat-Pre-ortho [1600x1200]

LatCeph

Treatment plan

In order to correct her teeth and jaw, we suggested to her that she might required orthodontic treatment for at least 6 months to a year, then followed by orthognathic surgery which will be done in a private hospital. She had to stay in the hospital for a few days for recovery before being discharged from ward and after that, she had to stay at home for a few weeks.

Following surgery, she had to continue brace treatment to fine tune her bite (a few months more) before to have the braces removed. After orthodontic treatment, she have to continue wear a retainer for at least a year to prevent the teeth from relapse.

Orthodontic treatment

The aim of orthodontic treatment was to ‘decompensate’ her teeth: meaning to ‘put’ her teeth back to the normal position to their respective jaw. At the end of orthodontic treatment prior to surgery, her teeth seemed to look worse than before.

This treatment was done by our orthodontist and it took her almost 9 months to have her teeth decompensated.

 

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Right side

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Front

Pre-op07 [1600x1200]Left Side

OPG-Pre-surgery [1600x1200]

OPG-presurgery

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LatCeph-presurgery

Surgical Planning

Three weeks before surgery, we planned the surgery detail – how much we are going to bring the upper jaw forward, how much to push her jaw backward and other consideration.

i) Radiographic planning/Lateral cephalometry analysis

The jaw bone and soft tissue were trace out onto a plastic sheet.  Then, by moving the plastic sheet, we moved the ‘jaw’ to the planned position. From there, we would know how much we moved the jaw during surgery. On the next step, we would have to cut the jaw models just as if we were cutting the real jaw in the operating theatre and stick the jaw models on planned position!!

Radiograph-tracing [1600x1200]

ii) Model surgery/planing

Plaster models of her upper and lower jaw duplication were mounted onto the articulator for surgical planing. It resembled of her bite and the relation of the upper to the lower jaw.

Model-preop [1600x1200]

Her jaw relationship before surgery

 The models on the articulator were cut according to the radiographic planning and from there we could appreciate the final out come of her biting and new jaw position (picture below).

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Upper jaw cutting and remounting

Model-Mandible push back02 [1600x1200]

Then followed by the lower jaw. Final position!!

Surgical Planing:

After model surgery/planning, we would have the idea of how much we were going to cut in order to place the jaws bone to the correct/planned position before plating.

Maxilla (upper jaw):

  • Advancement 6mm,
  • Differential impaction 3mm upward posteriorly, 3mm downwards anteriorly
  • Rotation to left 3mm

Mandible (lower jaw):

  • 6mm push-back to acheieve class I occlusion

A intermediate wafer and final wafer (A acrylic appliance to register the biting) were fabricated on the articulator. The wafers would be used to guide the surgeons to position the jaws in correctly before fixing the jaws in operation theatre.

Model-Maxilla advance01 [1600x1200]

Intermediate wafer was made after upper jaw cutting & mounting

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Final wafer was made after lower jaw cutting & mounting

Surgery Day

Weeks before surgery

  • Wires were placed on her teeth to allow the surgeons to tie her jaws for fixation during surgery
  • She was told to take B12 and Acid Folic to booster her haemoglobin
  • She advised to take multivitamin for general health

A day before surgery

  • She was admitted to the hospital where her blood sample was taken as a standard procedure before surgery
  • The anesthesiology doctor examined
  • Risk and complication were explained to her
  • She had to fast from 12midnight

Surgery Day

She was push to the operating theatre (OT) at 9am where surgery started at 10am.  At 3pm (5 hours surgery), the surgery ended and she was push to the recovery area in the OT before been push to high dependency ward. There was no complication during the surgery and it went successfully. She was sleepy due to the anaesthetic gas and on pain killer.

OPG-Post-surgery [1600x1200]

OPG-after surgery

Lat-Post-surgery [1600x1200]

LatCeph-after surgery

Post Surgery

Day one after surgery, her face swelled up. She was still on painkiller and started to take liquid diet. 3 days later, she was discharged from the ward and stay at home for a week for recovery. Picture below: 3 days post-surgery–prominent face and the lips swelling.

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Front

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Side

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Lips

 

A week later, her condition was improving, and the swellings were subsiding all around her face. She was already on solid food and she didn’t take any pain killer. Her biting was stable but she complaint of saliva drooling as a result of the numbness present over her lower lips. Post-surgery orthodontic began 2 weeks later by Dr. Sia to optimize the occlusion (biting) of her teeth.

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Front

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Side

Post-op day08-05 [1600x1200]

Front teeth

 

3 months later, No more saliva drolling, numbness improving on both lips.  Post-surgery orthodontic was on the way.

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Front

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Side

Post-op month03-04 [1600x1200]

Smiling

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Front teeth

 

6 months later,  Brace treatment was at the final stage. Numbness almost gone and the facial outline become obvious as the swelling subsided totally.

Post-op months06-01 [1600x1200]

Front

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Side

Post-op months06-03 [1600x1200]

Smiling

Post-op months06-04 [1600x1200]Front teeth

 

9 months later,  she had her braces removed. Her braces treatment finally came to the end and she was very satisfied with the result

  Post-op-month09-01

Front

 Post-op-month09-02

Side

Post-op-month09-04Smiling  Post-op-month09-03Front teeth

 

Conclusion: Before and After Surgery

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 Front View (Before)

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Front View (After)

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Side View (Before)

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Side View (After)

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Teeth alignment (Before)

Post-op-month09-03

Teeth alignment (After)