Background

Orthognathic surgery, or corrective jaw surgery, is performed to correct jaw and facial skeleton abnormalities. It is commonly used to address skeletal discrepancies that can cause functional issues with biting, chewing, speaking, and breathing and improve overall facial aesthetics. 

The goals of orthognathic surgery include: 

• Achieving proper alignment and balance of the jaws. 
• Alleviating functional problems related to jaw abnormalities. 
• Enhancing facial harmony. 
• Improving the occlusion (bite). 

Epidemiology

• The estimated number of individuals in the United States with developmental dentofacial deformities who could benefit from orthognathic surgery is between 1.5 and 2 million; of these, approximately 1 million have Class II deformities, and 0.5 million have Class III deformities.  

Anatomy

Pathophysiology

• Skeletal Abnormalities: Orthognathic surgery is commonly performed to correct malocclusions and skeletal discrepancies of the jaws. The pathophysiology lies in the abnormal growth and development of the facial skeleton, resulting in improper alignment of the jaws and malocclusion. 
• Malocclusion: The pathophysiology of malocclusion involves the improper positioning of the teeth and jaws, leading to functional and aesthetic concerns. 
• Functional Implications: Skeletal and occlusal abnormalities can have functional implications for the individual. These may include chewing, biting, swallowing, speaking, and even breathing difficulties. 

Etiology

The etiology of orthognathic surgery lies in the presence of skeletal and occlusal abnormalities that affect the jaws and teeth. These abnormalities can arise from various factors, including: 

• Genetic predisposition plays an important role in the development of dentofacial skeletal anomalies. Syndromic conditions like Apert syndrome, Crouzon syndrome, and facial clefts can affect the average growth and development of the facial skeleton.  
• Traumatic events can also lead to dentofacial skeletal anomalies. In mature individuals, traumatic injuries to the facial skeleton can displace standard skeletal elements, which may require repositioning through osteotomies.  
• Other etiologies that can contribute to significant dentofacial anomalies include neoplastic growth, surgical resection, and iatrogenic radiation. These factors can disrupt the standard growth patterns of the facial skeleton and result in skeletal discrepancies that may require orthognathic surgery for correction. 

Genetics

Prognostic Factors

• Severity of the skeletal anomaly: The degree of the dentofacial skeletal discrepancy and the complexity of the anatomical abnormality can impact the surgical outcome. 
• Age: The patient age can affect the prognosis. In general, orthognathic surgery is performed after the completion of facial growth, which typically occurs in the late teenage years.  
• Preoperative orthodontic treatment: The quality and completion of preoperative orthodontic preparation play a crucial role in the success of orthognathic surgery.  
• Surgical technique and experience: The surgical technique and the surgeon’s experience performing the procedure can significantly impact the prognosis. 

Clinical History

Clinical Presentation: Orthognathic surgery is typically performed to correct dentofacial skeletal abnormalities, such as malocclusions, jaw size discrepancies, and facial asymmetry. 

Physical Examination

• Facial Symmetry and Proportions: The examiner assesses the patient’s facial profile, looking for any asymmetry, disproportion, or deviations from the ideal facial esthetics. 
• Jaw Alignment and Relationship: The relationship between the upper and lower jaws is evaluated to determine any size, position, or alignment discrepancies.  
• Dental Examination: The condition of the teeth, including their alignment, spacing, crowding, and any dental anomalies, is assessed.  
• Facial Movements and Function: The examiner evaluates the range of motion and function of the jaw joints (temporomandibular joints) and the muscles involved in jaw movement.  

Age group

Associated comorbidity

• Patients undergoing orthognathic surgery may have associated comorbidities or conditions that can impact the surgical approach and prognosis. 

Associated activity

Acuity of presentation

• Some patients may seek surgical intervention early in life due to significant functional or aesthetic concerns, while others may undergo surgery later in adulthood for primarily aesthetic reasons.
• The timing of the surgery may also be influenced by factors such as the stability of the jaw growth and the completion of orthodontic treatment. 

Differential Diagnoses

• Dentofacial Skeletal Anomalies: This category includes conditions such as mandibular prognathism (an excessively prominent lower jaw), maxillary retrognathism (a retruded upper jaw), open bite, deep bite, facial asymmetry, and malocclusions resulting from craniofacial syndromes. 
• Temporomandibular Joint Disorders (TMD): Some patients with TMD may present with significant jaw joint dysfunction, pain, or abnormalities in the jaw joint structures. In some instances, orthognathic surgery may be considered part of the treatment plan to address the condition’s functional and esthetic aspects. 
• Facial Trauma: Severe facial trauma resulting in fractures or displacement of the facial bones may require orthognathic surgery to align and stabilize the fractured segments properly. 
• Congenital Facial Clefts: Conditions such as cleft lip and palate or other craniofacial anomalies may require orthognathic surgery to correct the underlying skeletal deformities and achieve optimal facial aesthetics and function. 
• Obstructive Sleep Apnea (OSA): In some cases of obstructive sleep apnea, where the upper airway obstruction is related to anatomical abnormalities in the jaws or facial structures, orthognathic surgery may be considered as part of the treatment plan to improve the airway and alleviate the symptoms of sleep apnea. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

• Preoperative Orthodontic Treatment: Patients often undergo orthodontic treatment to align the teeth and prepare them for surgical correction before surgery. 
• Preoperative Preparation: Patients may receive counseling and guidance on maintaining good oral hygiene, dietary modifications, and lifestyle changes to optimize their overall health before the surgery. 

• Anesthesia: General anesthesia is typically used during orthognathic surgery to ensure patient comfort and safety. 
• Pain Management: Medications such as analgesics are prescribed postoperatively to manage pain and discomfort. 

• Surgical Correction: The primary intervention is repositioning the jaws to achieve proper alignment and balance. This involves making controlled bone cuts (osteotomies) in the upper and lower jaws, repositioning them, and securing them in new positions using plates, screws, or other fixation devices. 
• Adjunct Procedures: Additional procedures may be performed simultaneously with orthognathic surgery, such as genioplasty (surgery to reshape the chin), rhinoplasty (nose reshaping), or septoplasty (correction of a deviated septum). 

• Preoperative Phase: This phase involves comprehensive evaluation, treatment planning, and preparation for surgery. 
• Surgical Phase: This is the surgical intervention where the orthognathic procedure is performed.  
• Postoperative Phase: After surgery, patients enter a recovery period that involves monitoring, pain management, wound care, and oral hygiene instructions.  
• Postoperative Orthodontic Treatment: Following the surgical phase, patients continue orthodontic treatment to fine-tune the bite, alignment, and overall aesthetics. 
• Long-term Follow-up: Regular follow-up appointments are necessary to monitor the surgery’s progress, stability, and long-term outcomes.  

Medication

Future Trends

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References

• Orthognathic surgery.ncbi.nlm.nih