How does jaw surgery correct facial asymmetry. What are the benefits of orthognathic surgery for patients with cleft palate. Can jaw surgery improve breathing and TMJ issues. What is the recovery process like after jaw surgery. How does 3D planning enhance jaw surgery outcomes. When is the optimal time to undergo jaw surgery for craniofacial conditions. What are the long-term effects of jaw surgery on dental health and facial aesthetics.

Understanding Hemifacial Microsomia and Its Impact on Facial Structure

Hemifacial microsomia is a complex congenital condition that affects facial development. This condition can manifest in various degrees of severity, ranging from minor asymmetry to significant facial deformities. Also known as Goldenhar syndrome or oculo-auriculo-vertebral spectrum, it primarily impacts the development of the jaw, ear, and facial structures on one side of the face.

In some cases, children may be born with a slightly smaller lower jaw or ear on one side. However, more severe cases can involve multiple areas, including:

• Eye
• Ear
• Cheek
• Upper and lower jaw
• Nerve function

It’s important to note that hemifacial microsomia can also affect other organ systems, such as the heart, kidneys, spine, and arms/hands. Therefore, a comprehensive evaluation is crucial for proper diagnosis and treatment planning.

Tailored Treatment Approaches for Hemifacial Microsomia

Given the unique nature of each case, treatment plans for hemifacial microsomia must be individualized. The primary objectives of treatment are to:

1. Provide the best chance for a happy and healthy life
2. Minimize the number of surgeries required
3. Reduce associated risks

For patients with severe asymmetry affecting the occlusion of teeth, TMJ pain, and popping, a combination of upper and lower jaw surgery with TMJ replacement may be recommended. This approach aims to correct the slanted bite, alleviate pain, and improve overall facial symmetry.

The Transformative Power of Orthognathic Surgery

Orthognathic surgery, commonly referred to as “jaw surgery,” is a powerful tool in correcting various jaw-related issues. This procedure involves repositioning the upper and/or lower jaw to address a range of problems, including:

• Malocclusion (misalignment of teeth)
• Sleep apnea
• Overbites
• Underbites
• Open bites
• Facial asymmetry (cants)

Orthognathic surgery is particularly beneficial for patients with a history of cleft palate. In these cases, the growth of the upper jaw may not keep pace with the lower jaw, resulting in misaligned teeth and difficulties with normal chewing.

The Role of 3D Planning in Jaw Surgery

Advanced 3D planning techniques have revolutionized the field of orthognathic surgery. This technology allows surgeons to:

• Design precise jaw movements
• Plan for final implant placement
• Enhance stability and predictability of surgical outcomes

By utilizing 3D planning, surgeons can better tailor the procedure to each patient’s unique facial structure, ensuring optimal results and improved long-term outcomes.

Jaw Surgery for Cleft Lip and Palate Patients: Addressing Unique Challenges

Patients with a history of cleft lip and palate often face specific challenges related to jaw growth and alignment. Common issues include:

• Insufficient growth of the upper jaw compared to the lower jaw
• Canted or misaligned jaw growth
• Difficulty chewing due to malocclusion

While not every cleft patient requires jaw surgery, it is a routine procedure for many individuals with craniofacial conditions. The timing of surgery is crucial, with most surgeons opting to wait until patients reach skeletal maturity to minimize the risk of future procedures.

Staged Approach to Jaw Surgery in Severe Cases

In cases where the discrepancy between the upper and lower jaw is severe, surgeons may opt for a staged approach:

1. Perform distraction surgery prior to full skeletal maturity
2. Plan for potential future surgeries to fine-tune results

This approach allows for significant improvement in jaw position and function while acknowledging the potential need for additional adjustments as the patient continues to grow and develop.

Nager Syndrome: Addressing Severe Mandibular Underdevelopment

Nager syndrome is a rare genetic disorder characterized by severe underdevelopment of the lower jaw (mandible). Patients with this condition often face significant challenges, including:

• Breathing difficulties requiring tracheostomy
• Multiple jaw distractions to gradually lengthen the mandible
• Potential for ankylosed (frozen and immobile) temporomandibular joints (TMJs)

Treatment for Nager syndrome typically involves a series of surgical interventions aimed at improving jaw function, breathing, and overall quality of life.

Innovative Approaches to TMJ Reconstruction

For patients with ankylosed TMJs, innovative surgical techniques can help restore jaw mobility and function. These may include:

• Custom TMJ prostheses
• Autologous tissue grafting
• Combined orthognathic and TMJ reconstruction procedures

By addressing both the structural and functional aspects of the jaw, these advanced techniques can significantly improve outcomes for patients with complex craniofacial conditions.

The Recovery Process: What to Expect After Jaw Surgery

Recovery from jaw surgery is a gradual process that requires patience and diligence. While individual experiences may vary, here’s a general timeline of what patients can expect:

• First few weeks: Swelling, discomfort, and limited jaw mobility
• 1-2 months: Significant reduction in swelling, improved jaw function
• 3-6 months: Continued healing and adaptation to new jaw position
• 6-12 months: Full recovery and realization of final results

During the initial recovery period, patients may need to follow a soft or liquid diet and adhere to specific oral hygiene instructions. Regular follow-up appointments with the surgical team are essential to monitor progress and address any concerns.

Managing Post-Operative Symptoms

Common post-operative symptoms following jaw surgery include:

• Facial swelling and bruising
• Numbness or tingling in the face and lips
• Difficulty speaking and eating
• Temporary changes in facial appearance

Patients are typically provided with detailed instructions on how to manage these symptoms, including the use of cold compresses, prescribed medications, and proper oral care techniques.

Long-Term Benefits of Jaw Surgery: Beyond Aesthetics

While improved facial symmetry and aesthetics are often the most visible outcomes of jaw surgery, the benefits extend far beyond appearance. Long-term advantages of successful orthognathic surgery include:

• Enhanced chewing function and digestion
• Improved speech clarity
• Reduced risk of dental disease and TMJ disorders
• Alleviation of sleep apnea symptoms
• Increased self-confidence and quality of life

By addressing underlying structural issues, jaw surgery can have a profound impact on a patient’s overall health and well-being.

Ongoing Care and Potential for Additional Procedures

While jaw surgery often provides significant improvements, some patients may benefit from additional procedures to further refine their results. These may include:

• Fat grafting to address residual facial asymmetry
• Rhinoplasty to improve nasal function and aesthetics
• Lip revision surgery for patients with a history of cleft lip

Ongoing collaboration between the patient, surgeon, and other healthcare providers is crucial to ensure optimal long-term outcomes and address any emerging concerns.

The Importance of Timing in Jaw Surgery for Craniofacial Conditions

Determining the optimal timing for jaw surgery in patients with craniofacial conditions is a critical aspect of treatment planning. Several factors influence this decision, including:

• Skeletal maturity
• Severity of jaw discrepancy
• Impact on function and quality of life
• Overall health and readiness for surgery

In general, surgeons prefer to wait until patients have reached skeletal maturity before performing definitive jaw surgery. This approach helps minimize the risk of future growth changes affecting the surgical results.

Exceptions to the Rule: Early Intervention in Severe Cases

In some instances, early intervention may be necessary despite the potential need for future surgeries. Scenarios that may warrant earlier jaw surgery include:

• Severe functional impairment affecting breathing or eating
• Significant psychosocial impact on the patient’s well-being
• Opportunity to guide subsequent growth and development

In these cases, a staged approach may be employed, with initial surgery to address immediate concerns followed by potential refinement procedures in the future.

Advancements in Surgical Techniques and Technology

The field of orthognathic surgery continues to evolve, with ongoing advancements in surgical techniques and technology enhancing patient outcomes. Some notable developments include:

• Virtual surgical planning and 3D printing of surgical guides
• Intraoperative navigation systems for increased precision
• Minimally invasive approaches to reduce scarring and recovery time
• Custom-designed implants and prostheses for optimal fit and function

These innovations allow for more predictable results, reduced surgical time, and improved patient satisfaction.

The Role of Multidisciplinary Care in Craniofacial Surgery

Successful treatment of complex craniofacial conditions requires a collaborative, multidisciplinary approach. Key team members may include:

• Oral and maxillofacial surgeons
• Orthodontists
• Plastic surgeons
• Speech therapists
• Audiologists
• Psychologists

By working together, these specialists can address the various aspects of a patient’s condition, ensuring comprehensive care and optimal outcomes.

As research continues and surgical techniques advance, the future of jaw surgery for craniofacial conditions looks promising. With ongoing improvements in planning, execution, and post-operative care, patients can look forward to even better functional and aesthetic outcomes in the years to come.

Jaw Surgery Before & After Photos

Jaw Surgery Before & After Case 1

Hemifacial/craniofacial microsomia includes a wide spectrum of severity and conditions, with many names including Goldenhar syndrome and oculo-auriculo-verterbral spectrum.
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Some children are born with a slightly smaller lower jaw or ear. Other children may have severe asymmetry affecting multiple areas including the eye, ear, cheek, upper and lower jaw, and nerve function. Other organ systems may also be affected, including the heart, kidneys, spine, and arms/hands, and need to be evaluated as well.
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As each and every child is unique, their treatment plan must also be tailored to their needs. The goals are always to offer the best chance at a happy and healthy life, while minimizing the number of surgeries and the risks involved.
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For this gentleman, the occlusion of his teeth was severely slanted, with TMJ pain and popping.
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To correct this, we performed upper and lower jaw surgery with TMJ replacement at the same time. We waited to do this until he reached skeletal maturity and had a long enough break from contact sports to heal.
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After the first few months of recovery, his jaw is free of popping and pain, and his symmetry is improved. Further procedures like fat grafting may be offered to further fine tune any asymmetry if desired.
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As you can see, we love our patients, especially ones we have cared for since they were little!

Jaw Surgery Before & After Case 2

Orthognathic surgery (aka “jaw surgery”) involves the repositioning of the upper and/or lower jaw to correct a number of problems.

Commonly we perform this surgery for our patients with a history of a cleft. Growth of the upper jaw may not keep up with the lower jaw. The teeth then do not line up, and normal chewing is affected.

We also perform this surgery for patients with sleep apnea, or other imbalances of the jaws including overbites, underbites, open bites, and cants (like with hemifacial microsomia).

Jaw Surgery Before & After Case 3

This handsome young man has a history of a unilateral cleft lip and palate.

He is seen here 7 months after jaw surgery (maxillary advancement, mandibular setback, and chin advancement), and 1 month after rhinoplasty.

His occlusion (or how his teeth fit together) is now centered and leveled, with the teeth now able to chew optimally. This will help with TMJ and dental health long-term.

The bony work also helped to balance his facial profile, giving his upper lip and chin more support.

The rhinoplasty improved his breathing by straightening the septum and supporting his nasal passages, like having a Breathe-Right strip on the inside of his nose.

His lip scar will also continue to improve after a re-repair and re-orientation of the muscle of his lip.

Jaw Surgery Before & After Case 4

Here is a sneak peek with one of our all-star patients with a history of a more rare facial cleft.

She has had multiple surgeries with another team, and came to our team for her jaw surgery to correct her malocclusion.

As with many of our cleft and craniofacial patients, her upper jaw did not grow as much as the lower jaw. The two jaws also did not line up well.

This can result in difficulty eating normally, facial imbalance, dental disease, and jaw pain.

For her, we performed 3D planning to design the movements and final implants to give more stability and predictability with her surgery.

She is seen here at 2 months, with more updates to come!

Jaw Surgery Before & After Case 5

This young man has a history of a repaired bilateral cleft lip and palate, and had difficulty chewing because his upper and lower teeth did not naturally come together.

The upper jaw often does not grow as much as the lower jaw, or may grow canted, in our patients born with a cleft.

Not every patient with a cleft will need this surgery, but it is one we perform routinely given the number of cleft and non-cleft craniofacial patients we see.

We usually wait until patients are fully skeletally mature before doing this surgery, to minimize the risk of needing to do any future surgeries.

Occasionally, the difference in the upper and lower jaw is so severe that we do perform distraction surgery prior to full maturity, knowing that we may need another surgery in the future.

He is seen here at 6 weeks after his operation, with his splint out and smile ready to show off!

Jaw Surgery Before & After Case 6

This patient has a history of Nager syndrome, with severe underdevelopment of her lower jaw.

The small size of her mandible has required her to have a tracheostomy her entire life. She has had multiple jaw distractions, where the mandible has been broken and gradually lengthened.

The combination of her condition and her surgeries had left her with ankylosed, or totally frozen and immobile, TMJ’s on both sides.

We performed custom TMJ replacements – similar to a knee or hip replacement – with the condyles replaced with titanium heads, and a titanium and plastic joint fossa custom made to fit at the base of her skull.

She is seen here at 6 weeks after her surgery, with her range of motion the best it has ever been. She continues to improve every week as she progresses with her physical therapy.

She has been able and wanting to talk more, too, and we look forward to repairing her cleft palate (which has never been accessible). One day we may be able to remove her trach as well!

Jaw Surgery Before & After Case 7

This hockey player had difficulty chewing due to an open and uneven bite.

Upper and lower jaw surgery (LeFort I advancement and bilateral sagittal split osteotomy) was performed to close and level his occlusion.

He is happily now back to full activities on his skates!

Jaw Surgery Before & After Case 8

The path to a new smile sometimes comes through our office. For jaw surgery.

Braces alone sometimes aren’t enough to get a smile just right.

If the upper and lower dental arches are too far apart, or the facial harmony would be improved, orthognathic surgery may be recommended.

The main goals are often to align the upper and lower teeth, to help with chewing food completely and safely, and to improve facial balance from the upper, middle, and lower face.

Here, mandible-only surgery with a bilateral sagittal split osteotomy was done to correct a class II malocclusion.

Jaw Surgery Before & After Case 9

The smile says it all!

About 1 in 3 patients with cleft lip and palate benefit from jaw surgery. Aligning the upper and lower teeth helps people fully chew their food, and reduces wear and tear on the TMJ’s.

We also consider facial balance and harmony when planning the surgery and final outcome.

Jaw surgery can often be done in a single surgery, sometimes involving just the upper jaw, and sometimes with the lower jaw as well.

Here, the amount of advancement was well over 10mm, which is the point at which we usually move towards distraction over a single surgery.

Distraction involves cutting the bone and freeing up scar tissue, but then gradually moving from the starting position by 1mm per day.

New bone is deposited in the space made as the upper jaw moves forward. The surrounding blood vessels, lining, and old scar tissue all expand and accommodate the new bony position.

We usually keep the hardware in place (much more comfortably after finishing advancement!) for 3 months while the new bone hardens.

At that point, minor adjustments can be made as needed with additional movement or augmentation, or just removal of the hardware.

Here, we performed some fat grafting to the upper lip, expecting about half of the fat to reabsorb and half to stay long term.

He is seen here at about a month after that surgery — we look forward to sharing more photos as all the swelling comes down!

Jaw Surgery Before & After Case 10

Jaw surgery is a big surgery and a big recovery, but can be worth it because it makes such a big difference.

At some point, if the upper and lower roots are just too far apart, no amount of orthodontics will allow the teeth to line up.

That difference leads to problems chewing, breathing, and speaking. Some people also are more self-conscious of their smile.

Here, a four-piece Lefort 1 was performed, to correct a difference in the transverse dimension, in addition to the anterior-posterior direction.

He is seen here at 6 weeks, well on the road to recovery!

Jaw Surgery Before & After Case 11

This patient had a cleft palate and Class III malocclusion, meaning her upper jaw growth had not kept pace with the lower jaw. i.e., the maxilla was further back than the mandible.

This difference in bite causes problems with speech and chewing, and can increase the wear and tear on teeth and the TMJ’s.

Here, a custom-planned Lefort 1 advancement and chin advancement (genioplasty) corrected her malocclusion, while also giving a little bit more chin definition without going through the recovery and risks of a BSSO for the mandible.

Jaw Surgery Before & After Case 12

What a pleasure taking care of our patients who need jaw surgery.

It can be a tough surgery and tougher recovery, but the benefits to breathing, chewing, and facial balance can be tremendous.

This man worked through the worst of it – the months of prep work, swelling, drainage, difficulty sleeping, and more – with superb care and composure.

In this case, additional bone grafting to the upper cheeks helped improve lower eyelid support and balance, and augmented the bony healing and stability after the osteotomy.

We look forward to watch him continue on to greater things!

Jaw Surgery Before & After Case 13

The smile says it all! Jaw surgery is used in cases where the upper and lower jaws are too misaligned to correct with braces alone.

Functional issues include difficulty with fully chewing and then choking on food, affected speech, and sleep apnea.

Long term, there may be problems with the TMJ, and supraeruption or loss of teeth and bone thickness. Obstructed breathing can cause a wide range of negative health effects, increasing the risk of obesity, diabetes, stroke, heart attacks, and more.

Thankfully we have worked for decades to get the surgery included under insurance (when meeting insurance criteria), with some of our most reliable partners right now Aetna and United Healthcare.

The recovery is significant, but so are the benefits!

Before & After Photos | Los Angeles, CA

Case Description:

A receding jaw can adversely affect your teeth and health and can result in obstructive sleep apnea, stomatognathic, and TMJ dysfunction.

Treatment time of surgery: 2 hours

Treatment time of distraction osteogenesis: 12 days, turning a proprietary distracter daily.

A short course of orthodontic treatment before and after the procedure was needed.

Case Description:

An imbalance of the jaws can significantly adversely affect the health of the teeth, jaws, and overall health. If left untreated, the damage is progressive, especially as one ages and the tissues become more susceptible to breakdown.

This patient chose to correct her jaw imbalance before the damage and deterioration progressed.

Treatment time of surgery: 3 hours

Orthodontic treatment:  6 months prior to surgery and 6 months after surgery due to her severe malocclusion (improper bite).

Case Description:

Danielle complained of strain of the lips, jaw pain, and an uncomfortable bite. Her dentist referred her in due to progressive gum recession and clicking and popping in her jaw.

Type of surgery: LeForte I, BSSO and Genioplasty

Duration of Surgery: 4 hours

Duration of orthodontic treatment: 11 months due to her malocclusion (improper bite), headaches and TMJ pain.

Following surgery the strain of her lips and mentalis muscle resolved. She reported her bite felt balanced and comfortable. The clicking and popping of the TMJ resolved and the micro-trauma of the malocclusion and mechanical cause of her gum recession was eliminated.

Danielle complained of despondency, depression, and feeling tired when she woke up in the morning after sleeping 7 hours. She felt a lack of energy and by the end of the day felt more tired. She thought that it may be affecting her memory and work.

The imaging taken at Jaw Surgery LA Imaging Center shows a narrow airway before surgery (left image) and a normal airway after surgery (right image).

Following treatment all of her symptoms resolved and she reported “a tremendous feeling of well being, energy and overall quality of life and happiness.”

Danielle also complained of a “gummy smile” that she said bothered her and made her feel “very self conscious” every time she smiled.

The maxillary impaction procedure and orthodontic treatment eliminated the “gummy smile” and restored a natural facial and muscle balance.

Treatment included palliative modalities and careful placement of the TMJ condyles into the physiologic centric position Rx by Dr. Jacobson, with complete resolution of her pain and dysfunction.

Case Description:

Stephanie complained of an uncomfortable underbite and a smile that bothered her. Her teeth were wearing down but her mother intercepted and brought her to our Orthodontic Center LA at an early enough age. As a result a jaw surgery was 100% prevented.

All treatment was completed by Dr. Jacobson using a  segmental technique and interceptive orthopedics taught to him by his mentors Dr. Ricketts and Dr. Tom Graber, after completing his specialty training at UCLA. Since then Dr. Jacobson has developed a series of additional effective techniques and protocols, for children and young adults to intercept and correct mild and moderate skeletal and dental malocclusions, without the need to do jaw surgery.

Before orthodontic treatment (left image) and after orthodontic treatment (right image). No jaw surgery was needed.

All children should be checked by a board certified orthodontist with extensive experience in cephalometrics and growth and development.

Most malocclusions (improper bites) can be improved if intercepted early, preferably before the permanent teeth erupt (come into the mouth). Early treatment can also significantly reduce the total active treatment time and enhance stability.

Most growth of the jaws is complete by age 15 years in a young woman and age 21 in a young man. After those ages, there are advanced orthodontic treatments that can be used to treat significant imbalances of the jaw and bite, but  jaw surgery can usually produce a much better result.

Case Description:

This patient complained of an asymmetry and uncomfortable bite with pain in both TMJ’s. If the jaw is anatomically asymmetric and disparate, jaw surgery can restore balance and symmetry.

Before surgery (left image) showing the strain of the lips and muscles contributing to the TMJ pain and imbalance. After surgery (right image) showing the surgical correction of the skeletal imbalance.

After surgery, bite adjustments and specially constructed TMJ splints can be used at night as retainers and protectors for patients that habitually clench or grind their teeth at night.

Ancilliary dental and restorative procedures are best done after the surgery is completed to refine the anatomy of any worn down teeth and to improve overall smile esthetics if patients want to enhance the size, shape, color or contours of their teeth.

Case Description:

Left image: Before a genioplasty (chin surgery).

Right image: After genioplasty (chin surgery).

Notice the normalization of the lip strain on the upper and lower lip after orthodontics and chin surgery. No upper jaw or lower jaw surgery was needed, only chin surgery.

A prosthetic chin implant typically performed by a plastic surgeon without maxillo-facial specialty training is NOT preferred for this procedure. A genioplasty (chin surgery) can be adjusted to decrease the lower facial height and the bone remodels.

A surgeon that is double board certified in Maxillo-facial and Plastic Surgery is preferred due to the subtleties involved in the management of the soft and hard tissues of the chin.

Before surgery this patient complained of an uncomfortable bite with lip and muscle strain. He had difficulty closing his lips and complained of a mouth breathing habit especially while sleeping with dry mouth and bad breath upon waking.

Dr. Jacobson used TAD’s (temporary anchorage devices) for 5 months in conjunction with orthodontic treatment to reduce his severe open bite, non surgically.  Then the chin surgery was completed to help restore facial balance and alleviate lip strain.

The chin surgery was completed in 1 hour under general anesthesia. The surgery was performed at our Jaw Surgery LA on site AAAHC certified Operating Room on a Friday. He recovered at home over the week-end and returned to visit us on Monday.

Typically the bruising and swelling from a genioplasty (chin surgery) procedure resolves within one to two weeks and no wiring of the jaws or elastics is needed.

Orthodontic treatment total time was 10 months to correct his severe open bite. TAD’s were only needed for 5 of the 10 months.

Case Description:

This patient visited Jaw Surgery Los Angles complaining of an uncomfortable bite and an inability to close her lips. She wanted to also improve her facial esthetics and profile. Her dentist told her she showed evidence of clenching or grinding her teeth, likely at night and she reported mild soreness in the muscles of the face.

The treatment included orthodontic treatment in conjunction with orthognathic surgery to help restore facial balance, and harmony. Post-treatment, she reports a very comfortable bite with no muscle tension. Her goals are to maintain a health bite and teeth for life without the need for extensive future dentistry.

There is seldom any need to ‘wire the jaws shut’ following surgeries performed at Jaw Surgery LA due to the orthodontic and surgical protocols followed for the past 20 years. All surgical incisions are made inside the mouth so there are no external of visible scars.

It is possible to prevent surgery on many patients before they have completed their growth. Men typically complete most of their growth of the jaws and face by age 21. Woman typically complete most of their facial and jaw growth by age 15.

All three children of this patient completed interceptive orthodontic at our Orthodontic Center LA and have not needed jaw surgery.

There are many advantages to diagnosing and intercepting malocclusions early, even before the permanent teeth erupt. Many times surgery can be prevented, and the overall extend of treatment is often much less with better short and long term stability.
Attachments area

Case Description:

This patient is highly intelligent, decisive and discerning. He wanted to correct his overbite to help protect his teeth from unnecessary damage from day to day chewing, biting and eating.

The treatment including a short course of orthodontics due to his malocclusion, in conjunction with jaw surgery at Jaw Surgery Los Angeles.

He is very happy with the overall improvements. He reported that most people he knew did not even realize that he had had any treatment or changes. He said that either people are not observant or the changes were subtle enough to go unnoticed. He himself fully enjoys this positive change.

Case Description:

This patient was referred to Jaw Surgery Los Angeles concerned that her teeth were wearing down unnecessarily. She commented that she is generally a happy person, but was incorrectly perceived as looking stern.

Her bite and jaw were uncomfortable and she was told that she snored while sleeping. Disparate jaw positions can adversely impact one’s airway and cause unnecessary snoring. Besides being annoying, and disruptive to quality sleep, snoring can prevent optimal oxygen intake and saturation during sleeping. This will in turn, regressively impact overall health and well-being.

Orthodontics in conjunction with jaw surgery can resolve obstructive sleep apnea and restore a more natural facial balance along with a bite correction. Changes can be rewarding in terms of general health in addition to the health of the teeth, bite, TMJ’s and facial musculature.

Case Description:

This patient flew in from Northern California, concerned about an underbite and a lack of teeth showing during smiling. She also had clicking and popping of the jaws, intermittent headaches, and an uncomfortable bite with lip strain.

The treatment and surgical correction of all malocclusions, especially malocclusions of the skeletal type, is complex.

The class 3 type malocclusion with an underbite is particularly complex. In a class 3 type malocclusion, the correction of the skeletal disparity must include a very careful analysis of the TMJ, airway, teeth, bite, soft tissues, and the extent of skeletal, facial, and muscular imbalance.

There is no such thing as a simple skeletal imbalance and the protocols established at Jaw Surgery Los Angeles adhere to for all types of skeletal and dental anomalies.

Optimal treatment does not always involve simply setting the lower jaw back in a Skeletal Class 3.

Paramount, is the pre-surgical stage of positioning of the teeth, into a position that facilitates optimal jaw surgery placement.

Patients want to look and feel good and want a result that can last a life-time.

Dentists and orthodontists want a bite that is a class one with the TMJ condyles centered into a physiologic centric position that is repeatable, very comfortable and mutually protected with immediate disclusion in protrusive function and all excursions.

ENT’s want to ensure there is an exceptionally good airway with no blockage in the nose or sinus congestion.

Speech pathologist and myofunctional therapists want to make certain the tongue has enough space in the mouth for best swallowing and speech.

Sleep specialists want the jaws positioned in a way to allow the air to flow optimally, including at the back of the mouth (retro-glossal and retro-palatally), with no excess soft tissue or uvula laxity or tissue excess that vibrates, causing snoring during sleeping.

Chiropractors, osteopaths, and physical therapists want to make certain the muscles of the face and neck are relaxed and not strained.

Everyone wants natural-looking smile. That is a lot to strive for.

Patients prefer not to have braces (orthodontic appliances) on their teeth. If needed, they prefer them for as little time as possible.

Fortunately, digital technology and protocols developed at Jaw Surgery LA allow us to significantly decrease the time of the pre-surgical preparation and the need for braces before and after surgery.

3-D imaging, intra-oral scanners and proprietary software also help us improve accuracy and decrease overall treatment times.

A comprehensive pre-surgical virtual protocol and resultant custom individualized jigs used during surgery also helps reduce the actual time of surgery. Shorter surgery times and well-integrated post-surgical protocols can help facilitate a much shorter and easier recovery.

All surgeries are rehearsed digitally prior to the actual surgery so patients and specialist can collaborate visually to better understand and appreciate the options, alternatives, and limitations inherent.

Case Description:

Chief complaint: Jaw pain, headache, facial pain and clicking of the TMJ with an overbite.

Procedure: Surgical movement of the lower jaw forward (Bilateral Sagittal Split Osteotomy)
Duration of Surgery: One hour
Orthodontic treatment specific for jaw surgery: 8 weeks

A protocol developed at Orthodontic Center LA and Jaw Surgery Los Angeles was followed.

One important part of this treatment was to establish the optimal position of the temporomandibular joint, specific for this patients’ structure and function.

Dentists, orthodontists, and surgeons are taught and typically use a TMJ position called Centric Relation (CR). There is much controversy regarding this position within the profession. CR is generally appropriate for most patients that are not in pain or do not have dysfunction.

This CR position was not used for this patient due to her ‘slipped disc’ (meniscus displacement) and loose TMJ ligaments (joint laxity).

Case Description:

Chief complaint: I am an actor living in India and just got an offer to do a very big movie with Netflix and I want to correct my overbite and create a more defined jaw.

I was referred to Jaw Surgery Los Angeles from one of the reputedly “best specialists world-wide” who said that the Jaw Surgery Los Angeles specialists are the best for this type of jaw surgery and worth flying to Los Angeles for.

“I am soooo happy with the results, was offered a leading role by Netflix and can’t thank you enough”.

This patient was specific about what he describes as a “Brad Pitt” jaw and brought us numerous photographs of what he liked.

We spend a considerable amount of time with him and his family, who flew to Los Angeles for the consultations. We were able to achieve the look and definition he wanted.

The surgery duration was 90 minutes, performed at our onsite AAAHC OR under general anesthesia on a Friday. The patient spend one night at a near overnight recovery center and returned for followup checkups on the following Monday. He described his total recovery as “surprisingly easy and fast” compared to what he had seen on the internet.

Case Description:

Chief complaint: “I am insecure and self conscious about my weak chin and tried to “get over it” but am struggling.

Surgical procedure: Wedge advancing genioplasty.

Duration of surgery: 1 hour (No external scarring, since all incisions are inside the mouth in the vestibule below the lower lip).

Orthodontic treatment needed: None specifically for a genioplasty.
Many times tooth movement is planned to ensure a Class I or an optimal bite and best placement of the teeth, for best functional and facial results.

A Genioplasty is not an implant.

Most plastic surgeons offer patients chin implants but a chin implant can resorb into the bone over time. Chin implants offered by Plastic Surgeons tend to look like an ‘add on’ and not natural, especially when the lower jaw and chin appear recessive like in the images above.

Specialists at Jaw Surgery Los Angles are board certified in Plastic Surgery but also board certified in Maxillofacial Surgery. The genioplasty procedure is carefully planned using 3-D imaging of the hard and soft tissues to help ensure the optimal placement of the chin.

The face is so delicate and small changes can make a very big difference.

Proprietary software and hardware allows surgeons to plan changes in size, shape, contour, position and symmetry.
Chins can be canted, protrusive, recessive, too long vertically, too short or asymmetric.

There is a lot of subtlety to chin surgery and it is best planned and performed by an experienced surgeon with dual board certification and training in both Maxillofacial and Plastic Surgery.

Case Description:

Chief complaint: “I had braces and lately my face is changing and sagging a little and it makes me look tired and old, but I am not tired and I feel young. I was referred to your Orthodontic Center by so many people that are very happy with their results and Dr. Jacobson recommends that I do jaw surgery for the best results for my condition”.

Surgery duration: 90 minutes under general anesthesia.

This patient said that she kept cold packs on and off her jaw, intermittently for the first 24 hours after surgery. She said she slept with her head slightly elevated for two nights following surgery. She reported very little swelling and a fast recovery with very little discomfort, even though she stopped taking pain medication days after her surgery.

All patients will experience swelling, especially the day after the surgery but protocols and recommendations developed at Jaw Surgery Los Angeles help significantly accelerate recovery.

Case Description:

“So many people I know that are really happy with their orthodontic treatment had their braces and Invisalign done at Orthodontic Center LA in Pacific Palisades”.

“I was referred to Jaw Surgery Los Angeles by Dr. Jacobson at Orthodontic Center LA, who said my chief complaint of a longer looking face and a slightly weak chin cannot be corrected by orthodontics alone but that combined with jaw surgery, I could get the result I was looking for”.

“I did not really want to change the way I looked, just improve my weak chin and be able to close my mouth better”.

“I love the results”.

“Friends that have not seen me for a while, say I look strong and healthy, like I have been working out. They have no idea that I had jaw surgery. I tell them and they say I look fantastic, but that they would never have been able to tell”.

“It is subtle but I love the change. When you see the before and after, it is an amazing result, even better than what I could have imagined.”

Duration of surgery: 3 hours under general anesthesia

Case Description:

Chief complaint: “I’ve always had an uncomfortable bite and jaw. I was very self-conscious growing up. I felt I looked ‘goofy’. Now my teeth are wearing, my gums are receding and my face is changing. It seems like this is slowly getting worse.”

Surgical procedure: Distraction osteogenesis of the mandible in conjunction with orthodontics.

Distraction, using curvy-linear distractors designed by Dr. Schendel, Professor Emeritus and founder of Jaw Surgery Los Angeles, allows directional distraction and optimal control in the forward, side to side and up and down direction. Dr. Schendel recruited Dr. David Dorfman DDS MD to succeed him as Chief of Surgery at Jaw Surgery Los Angeles.

Carefully controlled, distraction can enhance the vertical facial height as well as the overbite. Distraction also correct asymmetry. Advancing a lower jaw that is severely recessive with conventional jaw surgery is insufficient to fully correct severe jaw deformities. Distraction surgery allows a better result in these cases.

Case Description:

Case Description:

Case Description:

Case Description:

Case Description:

Surgical treatment of patients with mandibular fracture in the angle area using titanium nickelide brackets with shape memory. Clinical case

Introduction

Injuries of the maxillofacial region continue to be one of the urgent surgical problems, which is associated with an increase in the number of patients with fractures of the bones of the facial skull as a result of traffic accidents and domestic conflicts, the aggravation of this type of pathology, the growth of multiple and combined injuries [1, 2] . According to specialized literature, the proportion of maxillofacial trauma in the structure of various injuries among the urban population is 3.2–8.0% [3]. Mandibular fractures account for up to 85% of the total number of fractures of the bones of the facial skull [4–7]. The development and implementation of new methods for fixing bone fragments have significantly increased the effectiveness of surgical treatment in this category of patients, however, according to a number of authors, complications range from 5.2 to 38.4% of cases [8—11].

Many of the proposed techniques are successfully used in everyday practice for osteosynthesis in fractures of the facial skull – titanium plates, bone suture with stainless steel or tantalum wire, Kirschner wires, a combination of bone suture and wires is possible, fixing structures made of materials with shape memory. The purpose of this article is to describe the clinical use of titanium nickelide shape memory brackets (nitinol) for mandibular fractures at the angle.

Clinical case

Patient T. , 41 years old, was admitted to the clinic of maxillofacial surgery of the University Clinical Hospital (UCH) No. 2 of the First Moscow State Medical University. THEM. Sechenov with complaints of pain in the lower jaw on the right, aggravated by chewing and opening the mouth, swelling of the face on the right, malocclusion.

From the anamnesis it was established that the injury was received as a result of a fight with an unknown person 8 hours before going to the hospital. The patient did not report any commotional phenomena. Appealed to the emergency room, which produced x-ray of the skull and intermaxillary fixation with the help of Tigerstedt splints. The patient was delivered by an ambulance to the clinic of Clinical Hospital No. 2 of the First Moscow State Medical University. THEM. Sechenov, hospitalized on an emergency basis.

On admission: the general condition is relatively satisfactory. Somatic status without features. On examination, a pronounced swelling of soft tissues was determined in the parotid-masticatory, buccal and submandibular regions on the right. The skin in the fold was collected with difficulty, there was local pain on palpation. Regional lymph nodes are not enlarged. The symptom of direct and indirect loading is positive in the region of the angle of the lower jaw on the right. Vincent’s symptom was positive on the right. On the part of the oral cavity: the opening is limited to 2 cm, there was a violation of the closure of the teeth according to the type of open bite on the right. Ruptures of the mucous membrane of the alveolar part of the lower jaw in the region of 4.7–4.8 teeth were visualized, as well as the presence of hemorrhagic clots in the oral cavity. Swallowing is free, moderately painful (Fig. 1, 2, Fig. 1. Appearance of patient T. during hospitalization. Fig. 2. Orthopantomogram of patient T. during hospitalization. A violation of the integrity of the bone tissue in the region of the angle of the lower jaw on the right with the presence of a tooth 4. 8 is determined in the fracture line 3).

Rice. 3. X-ray of the skull of patient T. in frontal projection.

On the basis of complaints, anamnesis, clinical examination data and X-ray examination, the diagnosis was made: “Fracture of the lower jaw in the area of ​​the angle on the right with displacement of fragments.”

After additional examination and preoperative preparation, on the day of admission to the hospital, the patient underwent surgery: osteosynthesis of the lower jaw in the angle area on the right by external access using titanium nickelide brackets.

The operation was performed as follows: against the background of premedication under conditions of local anesthesia with Sol. Lidocaini 1% 20 ml, on the side of the fracture parallel to the edge of the lower jaw, retreating 2 cm in the angle area, a skin incision 4 cm long was made. The skin, subcutaneous fat, superficial fascia of the neck and m. Platisma. At the place of attachment to the angle of the lower jaw, the masticatory muscle proper was cut off. Skeletonized lower jaw in the corner. After visualization of the fracture line, small bone fragments were removed, interposition of soft tissues was eliminated, and blood clots were removed. Before osteosynthesis of the lower jaw, a free-lying bone fragment and tooth 4.8 were removed from the fracture line (Fig. 4). 4. Removed bone fragment, not connected with the periosteum, and tooth 4.8 from the fracture line. bone fragments were repositioned. The occlusion was fixed in the patient’s usual position with the help of rubber bands and osteosynthesis was performed using two Ω- and S-shaped titanium nickelide brackets under occlusion control (Fig. 5). Rice. 5. Stage of operation. Osteosynthesis of the lower jaw with Ω- and S-shaped titanium nickelide brackets.

The brackets were placed as follows: holes were formed bicortically on each fragment using a drill, then the bracket legs pre-cooled to +1–3°C were unbent to the sides (the bracket was activated) and inserted into the corresponding burr holes. When the bracket was heated to 35–36°C, the original shape was restored—the legs of the bracket approached each other, which led to dosed compression of the bone fragments. The postoperative wound was treated with antiseptic solutions, a latex graduate was installed. The wound was sutured in layers. Hemostasis was performed during the operation.

The postoperative period was uneventful. The patient was discharged for outpatient follow-up on the 7th day after surgery, after the removal of sutures. Mouth opening at discharge was 3.0 cm.

On the 2nd day after the operation, control radiographs of the skull in frontal projection and orthopantomography were performed. The position of the bone fragments and fixing structures was correct, no secondary displacements were detected (Fig. 6, Fig. 6. Orthopantomogram of patient T. after surgical treatment. 7).

Rice. Fig. 7. X-ray of the skull of patient T. in direct projection after surgical treatment.

At the control examination after 1 month, an increase in mouth opening up to 4. 2 cm was noted, the chewing function and the patient’s appearance were completely restored (Fig. 8). Rice. 8. a — appearance of patient T. 1 month after surgery; b — mouth opening amplitude of patient T. 1 month after surgery. As a result of dynamic observation and interdisciplinary treatment together with a physiotherapist, the appointment of physio- and vitamin therapy on the affected side, the sensitivity of the skin and teeth in the zone of innervation of the inferior alveolar nerve was restored after 6 months.

During a three-year follow-up period with examinations once every 6 months, a stable bite condition, absence of pain in the lower jaw and neuropathy of the lower alveolar nerve were noted.

Talk

Despite the development of medicine in general and maxillofacial surgery in particular, the problem of providing emergency medical care for fractures of the bones of the facial skull remains unresolved. In connection with the increase in the number of traffic accidents and domestic conflicts, the enthusiasm of young people for traumatic sports, there is an increase in the number of victims with injuries of the facial skull, among which fractures of the lower jaw occupy the first place [12].

The complexity of early diagnosis of fractures of the angle of the mandible is associated with insufficient information content of routine methods of X-ray examination (X-ray of the skull in frontal or lateral projection), late appeal of victims to specialized maxillofacial hospitals and, as a result, the choice of irrational methods of treatment, which in turn leads to to the development of various kinds of complications, a decrease in the quality of treatment and the life of patients.

Osteosynthesis for fractures of the lower jaw in the angle area using titanium nickelide brackets with shape memory allows you to securely fix bone fragments, minimizes the risk of complications due to long-term and dosed compression, and contributes to early restoration of the function of the lower jaw.

The authors declare no conflict of interest.

*e-mail: [email protected]

Medvedev U.A., https://orcid.org/0000-0001-6597-4875

Basin. E.M., https://orcid.org/0000-0003-1931-806

Zhang S., https://orcid.org/0000-0002-5121-1129

Petruk P.S., https://orcid.org/0000-0003-3686-2385

Jaw healed incorrectly after a fracture, methods of treatment

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In case of jaw fractures, it is necessary to provide specialized medical care in a timely and qualified manner, to carry out timely treatment of the wound and fixation of fragments. Under such conditions, fragments of the jaws grow together without complications and in the correct position. The consequence of violation of one of these conditions is that the jaws often heal with the displacement of debris, due to which fractures are formed that have not healed properly, and the wound heals in the form of rough scars that restrict the movement of the jaw, lips, tongue.

The nature of these deformations is very different. Incorrectly fused fractures of the lower jaw are characterized by violations of the dentoalveolar system and depend on the location of the fracture, the degree of discrepancy between the fragments, and the severity of the deformation. Of course, the appearance of the patient changes. There is an elongation of the face and tension of the soft tissues of the area near the mouth. Facial asymmetry often occurs. The displacement of the fragments of the lower jaw leads to the displacement of the articular heads, which leads to disruption of the functioning of the temporomandibular joint, as well as chewing muscles. A change in the position of the fragments of the jaws leads to a violation of speech, mainly due to a decrease in the volume of the oral cavity. The clinical picture is characterized by the degree of occlusal disorders.

Surgical treatment for fractures that have not healed properly with a slight functional impairment does not cause any particular difficulties.

Patients are divided into three groups. In patients of the first group, there is a tubercular appearance of occlusal contacts; in the second, the teeth contact only with lateral surfaces; in patients of the third group, the closure of the teeth is completely absent.

The method of treatment for fractures of the lower jaw that have not healed properly, of course, is surgical, i.e. fragments are repositioned and immobilized. In case of refusal of patients from treatment, prosthetic, orthopedic, hardware-surgical methods of treatment are used.

Tactics of therapeutic measures depends on the presence of teeth in the jaw.

Treatment of malunion of jaw fractures with preserved dentition has some peculiarities. First of all, it is necessary to pay attention to the age of the patient. So, if there are signs of an open bite, then at a young age orthopedic methods give good results, while in elderly patients with the same pathology, grinding of the teeth on which the bite is fixed, or even their removal, will be effective. Such tactics must be observed in the presence of other pathological bites, paying attention to the age of the patients.

From orthopedic constructions, plastic caps are widely used – crowns, cast crowns, metal-ceramic and metal-plastic caps or crowns, cast arch prostheses, and in very difficult cases – collapsible prostheses.