Maxillofacial Surgery

Maxillofacial surgery is dedicated to the diagnosis and surgical treatment of alterations in the development of adult facial bones.

Maxillofacial surgery is the intervention that corrects dentofacial asymmetries with the aim of achieving a perfect balance of the face and teeth. Dentofacial dysmorphisms are quite frequent in the general population.

Maxillofacial surgery

After a variable period of maxillofacial treatment, intervention is performed on the jaws to achieve a perfect balance between all the individual’s facial features, correct occlusion and improved breathing (achieving a greater passage of air through the upper airway).

As the position of the jaws changes forward, backward, up or down, the soft facial tissues (the chin, lips, cheeks and the end of the nose) also move with them. The height of the face can even change.

Thus, once the jaw is placed in a correct position, the facial profile becomes correct and harmony of the new facial features is produced.

Maxillofacial surgery is closely related to Orthodontics and, normally, the treatment begins with the extraction of the wisdom teeth, followed by orthodontic treatment prior to the surgery which lasts between 1 and 2 years, in cooperation with the orthodontist.

This time can be shorter, depending on the case. Therefore, the correction of dento-maxillofacial deformities always involves the orthodontist and the surgeon working alongside.

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Dento-facial deformity

Dentofacial dysmorphisms are quite frequent in the general population. Usually, people find it difficult to chew because their teeth do not fit together well or because they notice a change in the size of their chin with a negative influence on their self-esteem.

The problems where maxillofacial surgery is indicated are:

  • Mandibular prognathism or “big chin”;
  • Retrognathism or “small chin”;
  • Gummy smile or “gum showing”;
  • Open bite or “teeth do not match forward or backwards”;
  • Crossbite and facial asymmetry or “crooked or deviated face”.

These bone alterations result in an incorrect position of the teeth, with a negative impact on facial harmony/aesthetics. They can occur in isolation or in association with each other, and an individualised treatment plan must be created in order to obtain the best functional and aesthetic result in each case of maxillofacial surgery.

Maxillofacial surgery is a procedure that always involves the association of orthodontic treatment before and after surgery. After orthognathic surgery, intensive rehabilitation treatment should always be associated.

Alterations to the length, width or height of the jaw translate into difficulties in the accommodation of the teeth and also into a change in the relationship between the upper and lower teeth. The teeth try to adapt to this lack or excess of bone, adopting different positions to those they would have if the structure were correct.

Excessive gum showing when smiling, not being able to bring the lips together completely without effort, not showing the upper teeth when smiling, jaw backwards, jaw forward, crooked teeth in the jaw, facial asymmetries, chin backwards, chin forwards, are some of the main complaints people have.

These problems, being of the jaws and teeth, should be treated together with Orthodontics (to correct the teeth malpositions) and surgery (to put the jaws in the correct position). Otherwise, unsatisfactory results can be achieved, indefinite and recurrent orthodontic treatment.

Often the face asymmetries are significant, for example, a deviated chin, and origin major aesthetics compromises.

What are the most common facial alterations and malocclusions?

As already mentioned, when there is a discrepancy between the position of the maxillary bone and the mandible, there is what is known as a skeletal malocclusion, which can be of two types in relation to the anteroposterior plane:

  • CLASS 2: also known as mandibular retrognathism and/or maxillary prognathism. It occurs when the maxilla is advanced in relation to the mandible.
  • CLASS 3: also known as mandibular prognathism and/or maxillary retrognathism. It occurs when the mandible is advanced in relation to the maxilla.

Other common malocclusion problems are narrow palate, open bite, cross bite, edge-to-edge bite, overbite or tooth crowding.

Apart from malocclusions, misplacement of the jaw bones can also cause other malformations such as:

  • Facial asymmetry: when one side, or part of one side of the face, is out of balance with the other ;
  • Gummy smile: when an excess of gum (or gum) tissue is shown when smiling.

Where should you go to solve the above problems?

A person who identifies these problems can go to a centre specialising in maxillofacial surgery and/or to their orthodontist for an initial consultation.

Once the two professionals assess the individual’s complaints and expectations, the dental situation, the occlusion and size of the jaws and the person’s facial harmony, they decide whether orthodontic treatment is sufficient or whether maxillofacial surgery is necessary.

Why is it necessary to treat malocclusion?

In the case of malocclusion, the tissues surrounding the tooth are injured when chewing food, inflammation occurs and the bone begins to lose thickness. As the bones become thin, the mobility of the teeth increases, gaps may appear between the teeth;

On the other hand, if the teeth are in the wrong position, dental plaque starts to accumulate quickly and causes inflammation of the tissues surrounding the tooth; then decay damages the teeth.

On some occasions, malocclusion can create injuries to the temporomandibular joint due to overload.

Finally, malocclusions have a strong negative impact on the aesthetics of the smile.

When can maxillofacial treatment start?

It is extremely important to notice the incorrect growth of the jaws in children between 9 and 13 years of age, as it is precisely at this age that the situation can be corrected through the application of functional orthodontic appliances. The treatment lasts approximately one and a half years.

In the case of people over 13 years of age, if the jaw alteration is already established, orthodontic treatment can be started. The duration of the treatment period is 1 to 2 years.

There are no age-related limitations for orthodontic treatment; however, orthodontic treatment of older people can be more complicated and last longer. As the years go by, bone tissue resorption occurs, which makes orthodontic management more complicated.

When is maxillofacial surgery treatment performed?

Maxillofacial surgery can be performed on individuals over 18 years of age. The complete orthodontic-surgery-orthodontic treatment takes 2 to 3 years, in cooperation with the orthodontist.

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What will the first maxillofacial surgery appointment be like?

A surgeon will evaluate the case and collect some necessary information, such as complaints and examinations, problems in dental occlusion and if you suffer or have suffered from any diseases or allergies.

All this information will be collected along with facial and dental analysis for a complete record of the clinical case; this information will be passed on to the orthodontist in order to draw up the most suitable treatment plan. If the individual does not have a referral orthodontist, information will be provided for the most appropriate choice.

If you already have an orthodontist, you should take with you: a panoramic x-ray of the oral cavity (orthopantomography), a lateral x-ray of the head and dental plaster models. If you do not have an orthodontist, these will be planned.

For registration and clinical analysis, photographs will be taken of the front and profile.

During the presentation of the treatment plan, aspects such as treatment details, approximate duration, risks and possible complications will be discussed.

What happens during the pre-surgical orthodontic treatment?

All wisdom teeth must be removed before orthodontic treatment begins. Extraction may be performed before the start of orthodontic treatment or during treatment, but in all cases at least 6 months before maxillofacial surgery.

Extraction of two or four healthy teeth may be necessary because of a substantial mismatch between the sizes of the dental arches or crowded teeth.

The aim of pre-operative orthodontics is to eliminate any existing dental compensation and provide the surgeon with a stable and adequate structure between the upper and lower arches, aligning the teeth in order to perform the planned skeletal movements, this goal is usually achieved within 12-18 months. Post-operative orthodontic treatment is essential to establish a proper occlusion at the end of treatment.

Once the teeth are in the ideal position for surgery, the pre-operative study is carried out by performing a 3D CAT scan, new dental records and photographs, which will be studied by the surgeon with the aim of perfectly planning the case with millimetric precision, with the support of 3D digital programming methods.

Virtual planning in maxillofacial surgery was introduced in the last decade and offers the surgeon the best diagnostic and planning tool available today. With the use of Cone Beam Tomography, scanning models and 3D planning software one can plan, simulate and perform surgery with millimetre precision.

In this way, the surgeon is able to exchange information with the orthodontist, simulate and evaluate the surgical possibilities even before the surgery is performed, ensuring greater predictability of the case and greater satisfaction for the person.

Besides assisting in planning, the 3D software ensures more information and precision during the execution of the surgery itself, reducing the time and surgical trauma during the procedure.

One week before the operation, a muscular evaluation of the cervico-facial and swallowing muscles will be performed to evaluate the individual functionally again in order to compare him/her with the therapies that will be performed in the post-operative period. The requests for preoperative examinations will be delivered and evaluated by the surgeon and the anesthesiologist.

What are the new advances in maxillofacial surgery?

In the planning of the surgery using 3D technology, as mentioned in the previous point, achieving greater surgical precision and prediction.

When performing surgery: Ultrasonic surgery or surgery assisted by piezoelectricity, making the cuts in the bone (osteotomy) by ultrasound which does not affect the soft tissues and is much more precise and less traumatic for the hard tissues.

Post-operative: Hiloterm ® facial cooling mask, Hilotherm is an equipment that works with anatomical accessories for all parts of the body, is indicated as the most effective and modern method in the recovery from post-surgical trauma by means of cryotherapy/thermotherapy effective to relieve pain and swelling by keeping the face with a continuous and controlled temperature in 15ºC.

What should I know before maxillofacial surgery?

Maxillofacial surgery is a planned procedure and therefore is not performed if the person has an active infection, in which case the intervention will be postponed until the clinical situation is suitable;

The stomach must be empty before surgery;

Eating and drinking in the morning before surgery is strictly forbidden. This is an extremely important rule – if stomach contents enter the airways, it can lead to a fatal outcome;

The operation is always performed under general anaesthetic.

 

What are the feeding and hygiene rules after surgery?

During the first weeks after the surgery, feeding should be based on liquids, then the surgeon will guide the progressive introduction of food.

Oral hygiene is a fundamental element in this phase and must be performed with a soft-tipped brush several times a day, along with oral rinses and the application of antiseptic oral gel.

Do I have to wear elastics on my teeth after the surgery?

The correct placement of the elastics is fundamental for a correct result. From the moment the intervention is finished, they will be placed to help its stability. These must be removed during meals and put back on again after oral hygiene.

They must be completely changed once a day. The surgeon will guide their placement during the first few weeks after maxillofacial surgery. Progressively, the times without elastic support will be longer and the elastics will be of lesser strength.

The surgeon should accompany the individual at least until the removal of the orthodontic appliance.

Types of Maxillofacial Surgery?

Maxillary Surgery

Maxillofacial surgery on the jaw is performed to place the jaw in the correct position to achieve facial harmony, and most importantly, a recovery of the functionality of this bone, which is the key to chewing, breathing and speaking.

This procedure is performed to correct various facial deformities, such as mandibular prognathism or Class 3, open bite or gummy smile.

Maxillofacial jaw surgery consists of a cut in the jaw bone called the Le Fort I osteotomy, which allows for advancement, retrusion, lengthening, shortening or rotation of the jaw bone. Once in the desired position, the jawbone is fixed with plates and screws made of titanium, a completely biocompatible material.

Jaw Surgery

Due to the risks involved in jaw reduction surgery (narrowing of the airway), the most commonly practised orthognathic jaw surgery is mandibular advancement surgery. This procedure is necessary when people have a small mandible that is retracted in relation to the maxilla, a condition known as retrognathia or class II.

The mandibular setback is reserved in cases of marked mandibular prognathism in class III usually in combination with maxillary advancement surgery in the context of bimaxillary surgery.

This type of malformation especially affects the harmony of the lower face and causes various functional problems such as sleep apnoea.

The mandibular advancement surgery consists of a cut on each side of the jaw bone called a bilateral sagittal osteotomy, an advancement of the bone and fixation of the bone in the new position by means of titanium plates, a completely biocompatible material.

Maxillomandibular or Bimaxillary Surgery

In most people with dentofacial changes, it is necessary to reposition the maxilla and mandible to achieve correct occlusion and facial harmony. This procedure is known as maxillomandibular surgery or bimaxillary maxillofacial surgery.

Bimaxillary maxillofacial surgery is used to treat the following malformations: Class 2, Class 3, facial asymmetry, or open bite, among others, when a monomaxillary surgery is not enough to repair the individual’s problems.

Mentoplasty, as explained ahead, is chin surgery, and in order to achieve a result of excellence in cases where it is necessary, it must be performed at the same time as maxillofacial surgery.

The surgery is performed by incisions inside the mouth, the wounds take ten days to heal, the stitches are absorbable and, on average, the mandible is consolidated in 2 months, and the maxilla in 4 months.

The average stay at the surgical site is one day. A facial cooling device will be placed to minimise post-operative oedema and lymphatic drainage will also be performed on the second post-operative day.

During the 3 months after surgery, several physiotherapy and speech therapy sessions will be performed along with the surgeon’s monitoring for excellent functional recovery.

Mentoplasty

Mentoplasty is a very safe outpatient chin surgery with great results. In some parts of the world, this surgery even supplants other types of aesthetic surgeries such as liposculpture or mammoplasties.

The chin, besides being one of the most important parts in defining our face, is also one of the facial signs of gender, which causes more and more people to resort to mentoplasty to increase, decrease or symmetry their face.

This surgery is performed through a small incision inside the mouth (leaving no scar), where the chin bone is increased or decreased, and a custom-made prosthesis can also be used to achieve the desired facial aesthetic result.

This type of technique leaves a permanent result on the individual and there are other techniques such as infiltration with hyaluronic acid or infiltration with fat from liposuction of the thighs or belly for chin treatments.

Recently, chin contour shaping or contouroplasty has become a high-performance technique in facial aesthetics.

One of the great advantages of mentoplasty is its light postoperative period in relation to other aesthetic surgeries and the evidence of the final result in a short period of time.

Dentofacial Deformity Pathologies

Sleep Apnoea

Sleep apnoea and how to solve it with maxillofacial surgery

Obstructive Sleep Apnoea Syndrome (OSAS) is a disease that consists of repeated episodes of breathing pauses during sleep, the apnoeas, generally longer than 10 seconds. The main cause of obstruction is the collapse of the walls of the upper airway.

Obstructive Sleep Apnoea Syndrome affects a little more than 25% of the population and has a very negative impact on the quality of life of those who suffer from it.

Not only their rest during the night, which in extreme cases can even lead to death but also their daily activity, accompanied by drowsiness and chronic fatigue.

Even more serious, Sleep Apnoea causes a reduction in the oxygen carried by the blood, leading to high blood pressure, cardiovascular diseases, metabolic and hormonal disorders and an increased risk of accidents.

Symptoms associated with sleep apnoea

The presence of two of the following symptoms, in the absence of other causes, can be an indicator of Obstructive Sleep Apnoea Syndrome:

  • Irregular, loud, interrupted snoring (Accompanied by sleep apnoea);
  • Fatigue during the day;
  • Chronic fatigue.

Diagnostic test

The diagnosis of Sleep Apnoea is made through a test called polysomnography, which monitors several variables during sleep using special devices.

This test is performed by the Neurophysiology team, so maxillofacial surgeons, being a multidisciplinary disease, must coordinate between the whole team of specialists, usually pulmonologists, neurophysiologists, and otorhinolaryngologists.

Treatment of sleep apnoea: levels of action

Four levels of performance are commonly described in the treatment of Obstructive Sleep Apnoea Syndrome:

  • Weight loss;
  • CPAP;
  • Mandibular advancement splints;
  • Maxillofacial surgery.

One of the treatments that has been recommended for many years is CPAP, an acronym for “Continuous Positive Airway Pressure”, a nocturnal device consisting of a mask connected to a machine, which blows in compressed air and prevents the collapse of the individual’s airways.

Most people who have suffered from Sleep Apnoea describe the CPAP as a “hellish” machine. Intolerance to noise and mask, nasal congestion, and mucosal irritation, make up to 70% of people want to abandon CPAP and find a much more comfortable and effective alternative.

On the other hand, mandibular advancement dental splints are a diagnostic element and also a temporary solution for mild cases of Sleep Apnoea. According to recent studies, prolonged use of this brace may cause changes in the way of biting and deterioration of the temporomandibular joint.

Thanks to their continued dedication and intensive research into Obstructive Sleep Apnoea Syndrome, today specialists at the Maxillofacial Institute, together with other groups at an international level, have scientifically demonstrated that maxillofacial surgery is the definitive solution to this serious problem in people who present with dentofacial deformities.

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