Surgical Treatment to Correct the Faulty Jaw: Frequently Asked Questions

[drsushant]

What does “faulty jaw” actually mean?

The faulty jaw can be either congenital or developmental in nature, or from a traumatic injury. Faulty jaw is another word for malposition of the jaw or jaws.

What kind of problems can arise by having a misaligned jaw cause?

When we talk about problems that the malaligned jaw can cause, we should mention difficulty with chewing and speech, and some people think problems with the temporomandibular joint, or TMJ. Faulty jaw position can also create problems with sleep apnea and we in fact advance the lower jaw and sometimes the upper jaw to aid with obstructive sleep apnea symptoms.

Can braces do damage to the jaw?

In general it is felt that orthodontic therapy is not specifically related to damage or problems with the jaw.

What is TMD?

TMD is “temporomandibular joint dysfunction”. Like all joint problems, the causes are multifactorial and some people believe malposition of the jaw is one of these causes.

I grind my teeth at night, is this cause by a problem with my jaw?

Bruxism or grinding teeth at night or during the day for that matter can be associated with malposition of the jaw. Occasionally when the teeth do not meet correctly, it can facilitate or encourage grinding of the teeth. This of course can create muscle spasm or a “tired jaw.”

What are other options, non-surgical for TMJ, TMD??

Non-surgical treatment for TMJ or TMD include physical therapy, the use of medicinal therapy including non-steroidal anti-inflammatories such as ibuprofen, the use of muscle relaxants, and occasionally in severe problems, the use of narcotics on a temporary basis.

I was in an accident and broke my jaw. Will it heal properly? What should I be concerned about?

With respect to a broken jaw, this certainly can be a cause of a faulty jaw position. I am assuming the broken jaw was in the lower jaw, or the mandible. In general, mandibular fractures are treated by closed or open reduction. A closed reduction involves wiring the teeth together for approximately 6 weeks. This acts as a “cast” to keep the jaw from moving. The other way to treat a mandibular fracture would be to utilize an open reduction and internal fixation. Fixation would involve the use of small titanium plates and screws to reduce the fracture and to minimize the time the patient is wired together. One of the more important aspects of mandibular reduction is to seat the occlusion or bite, as it existed before the accident. If these things are accomplished, it is very likely the mandibular fracture will heal. Occasionally when a malaligned jaw occurs from a traumatic incident, meaning did not heal correctly, we go back secondarily and perform an osteotomy or bone cut, to allow realignment of the jaw.

What types of materials are used in jaw joint surgery?

With respect to temporomandibular joint surgery and materials utilized during surgery, we have become very conservative with our approach. Many autogenous (or materials that come from the patient) can be utilized. These might include cartilage, muscle, or fascia lata. In severe cases, alloplastic or artificial joint replacement is undertaken. But I must emphasize this would be for a severe case.

        

[drsushant]

What is TMJ? What causes it? Are there any ways to correct it?

The temporomandibular joint is the articulation between the mandible and the skull. The actual joint is immediately in front of the ear. You can feel your TMJ by placing your index finger in front of your ear and opening the jaw. What you are feeling is the condyle of the lower jaw. When people speak of problems with the temporomandibular joint (TMJ), there are many potential causes that lead to difficulties. One contributing factor is stress, others include muscle imbalance, severe jaw malposition, and displacement of the normal anatomy or cartilage that lies between the mandible and the skull.

Are there any synthetic material used in jaw surgery? Is it possible for people to be allergic to these materials?

There are synthetic materials used in jaw surgery. Typically in an osteotomy we will reposition the bones using titanium screws and plates, which eliminates the need for wiring the teeth together. In general, people are not allergic to surgical-grade titanium. That is not to say, however, that one could not be allergic to titanium. Titanium has generally replaced surgical-grade stainless steel.

Is chewing gum bad for your jaw?

Gum chewing is not necessarily bad for your jaw. However, like most joints, overuse can eventually lead to problems. Since the jaw joint, or the mandible, moves each time we swallow, speak or eat, it obviously is used to a great extent. Thus, if you are prone to sore jaw joints or have TMD, I would recommend against parafunctional habits including gum-chewing, fingernail chewing, chewing on pens and pencils, and opening your jaw excessively wide to “dislocate.”

What is the typical recovery time?

Following a jaw osteotomy, the recovery time varies depending on the desired activity. A jaw surgery patient is usually hospitalized overnight. They are typically restricted from heavy activity or lifting over 30 pounds for approximately 1 month, and then they are restricted to non-contact sports for 3 months. We would allow our young patients to return to full contact sports in 12 weeks. Any surgery of the jaw also requires a change in diet. The diet is typically liquids for several days followed by no-chew food for approximately 1 month with a gradual return to a normal diet starting at 6 weeks. If the surgery requires the jaw to be wired together, then the diet would be liquids for the full 6 weeks.

Does a cleft palate have anything to do with the jaw?

A cleft palate is often associated with a cleft lip and alveolus. The patient usually undergoes several surgeries in the area of the cleft at an early age. Because of this early surgery, the normal growth pattern of the upper jaw is restricted. Thus, it is often necessary to advance the upper jaw when the patient is in the mid to late teens.

How do you wire a jaw shut?

The teeth are wired together utilizing horizontal wires that go around the teeth. This is done in both the upper and lower jaws, and then vertical wires are used to connect the horizontal wires. We also utilize arch bars, which are wired to the teeth, and then they are connected utilizing vertical wires between upper and lower jaws. We ask patients who are wired together to carry wire cutters with them in case they are involved in an accident. It is usually not necessary for patients to cut their own wires.

        

[Anonymous]

Can a toothache indicate a problem with the jaw?

A toothache certainly can indicate a problem within the jaw. Whenever a toothache occurs, it should be evaluated to prevent any potential infection from spreading into the jaw or surrounding soft tissues.

Why would you wire the jaw shut — can’t you surgically advance the jaw without wiring?

With most osteotomies or major jaw surgery to move the jaws, it is not necessary to wire the teeth together. Instead, we use titanium plates and screws to secure the jaw into the new position.

Isn’t wiring a jaw shut painful?

The use of wires to close the upper and lower jaws together is not painful because of the use of local anesthetics, conscious sedation, and occasionally general anesthesia

With jaw surgery, are any scars visible?

There are generally not any visible scars when major jaw osteotomies or cuts and movements are accomplished. The majority of incisions are intraoral or inside the mouth. The oral mucosa or tissue has an amazing capacity to heal and even intraoral scarring is minimal.

I have a severe underbite and would like to get it fixed. Should I consult a surgeon like you, or a plastic surgeon?

With respect to a patient with a severe underbite, first and foremost, one should visit an orthodontist. Correction of a malaligned or an underdeveloped jaw requires a combined effort, usually including an orthodontist and an oral and maxillofacial surgeon. Plastic surgeons also do osteotomies. I would recommend relying on your orthodontist for ultimate referral.

What is JRA?

JRA is “juvenile rheumatoid arthritis”. This condition will involve both temporomandibular joints. Fortunately, unlike adult rheumatoid arthritis, this process tends to “burn out” as the child reaches their late teens. The ultimate diagnosis of JRA does not come specifically from the observation of TMJ changes.

There is a new trend for moving facial bones called distraction osteogenesis. This is essentially moving the bone very slowly after making a corticotomy or bone cut, that movement being approximately 1 mm per day. This can be accomplished with an intraoral or extraoral device. Distraction osteogenesis is not a replacement for routine orthognathic or jaw surgery, but has been an exciting addition to our surgical options for treatment of assymetries and the severely underdeveloped jaw.

What kinds of pain medications are normally prescribed to a patient after jaw surgery? Does welling often occur?

Following jaw surgery, we typically prescribe a mild analgesic. It is not usually necessary to give antibiotics beyond the final dose give intravenously in the recovery room. With upper jaw surgery, we often give a nasal decongestant to decrease swelling of the nasal mucosa. Otherwise, no other medications are generally prescribed. With respect to swelling, we utilize peri-operative high-dose steroids. This limits the amount of swelling that occurs from surgery and facilitates patient comfort. Patients are not swollen to a great extent; however, the amount of swelling varies from patient to patient.

what is the percentage of people who will experience an infection after surgery?

The incidence of infection following orthognathic or jaw surgery is very low. In the literature, the incidence is reported to be between 6 and 15 percent. These figures are high, in my opinion. When it occurs, the infection is easily treated with antibiotics and drainage with minimal discomfort and no long-term sequelae.

Is there any long term follow up needed?

Following a jaw osteotomy, we have patients return for numerous postoperative visits. We see patients typically at 1 week, 3 weeks, 6 weeks, and 12 weeks following surgery. We also see the patient back at the 6-month and 12-month intervals. This is to assure that the proper jaw correction has been obtained, is stable, and that there is not an infection or any other postoperative complications.

        

[Anonymous]

What can be done to prevent infection?

During jaw surgery, we utilize high-dose perioperative intravenous antibiotics for prophylaxis to prevent infection. Meticulous surgical technique and accomplishing the surgery in an efficient manner will also reduce infection rates. Occasionally, if bone graft is utilized during osteotomy, we will continue the antibiotic therapy for 7-10 days orally after discharge.

Like the Ilizarov leg lengthening procedure?

Jaw distraction osteogenesis is based on the Ilizarov leg lengthening procedure. In many ways, it is more successful and reliable in the head and neck region versus the extremities because of the ample blood supply found in the head and neck.

How often is this jaw distraction performed?

The distraction osteogenesis procedures are somewhat new, and are being utilized for the more severe deformities. It is also being utilized very early in life to advance the lower jaw and prevent the need for a tracheostomy in children with microgenia or micrognathia.

I have two bumps on my lip. How do I get rid of them?

With regard to bumps on the lip, I would advise seeking the opinion of a physician or dentist. Many bumps on the lip can be related to the minor salivary glands. There are, of course, many other causes.

Over what period of time is the distraction completed, and what kind of followup?

Let’s look specifically at mandibular or lower jaw distraction osteogenesis: once the bony corticotomy or cut is made, and the distraction device is placed, the distraction rate is approximately 1 mm per day. Thus it is possible to advance the lower jaw approximately 14 mm in 2 weeks’ time. This obviously is a large advancement. Once the jaw has been advanced, it is necessary to “lock up” the distraction device with the jaw in the advanced position. This allows the newly formed bone to calcify and heal. One other advantage of distraction osteogenesis is that the soft tissue envelope meaning muscle and skin readily, follow the bone.

What is the likelihood that you would lose sensation in your mouth after surgery?

Following orthognathic or upper/lower jaw surgery, there will be neurosensory changes. The nerves involved with jaw surgery are not motor, meaning surgery will not affect how your face looks or moves. In the lower jaw, the numbness will include the lower lip, chin and gum tissue, and in general, this should resolve in about 3 months. Sometimes neurosensory changes take up to 18 months in an adult to resolve. Occasionally, minor neurosensory changes of the lower lip and chin can be permanent. Permanent numbness following an upper jaw (maxilla) procedure is less common.

Is there a great chance of infection at the pin sites?

These pin sites are remarkably free of infection; however, one complication with the pin sites is stretching of the skin and scarring. Thus, there is a great push to develop smaller and more efficient intraoral distraction devices to eliminate this problem.

How is it locked up?

When one is using distraction osteogenesis, it is the patient’s caregiver or the parent who will activate the appliance either once or twice per day. The device specifically clicks, indicating a 1-mm advancement, and after achieving the desired movement, there is a locking mechanism to keep the device in its final position during healing. Some devices have different measurements; meaning 1 click might equal 0.5 mm.

Is it dangerous to nerves in jaw?

Distraction osteogenesis can also affect the sensory nerves within the bone; however, patients are generally young and neurosensory recovery is good. The distraction device is usually left in place for approximately 6 weeks following the last distraction movement or after it is “locked up.” If the device is an extraoral appliance, it is usually quite easy to remove the pins and often does not require a general anesthetic.

        

[Drsumitra]

Botulism toxin (BTX) is produced during the growth and autolysis of the strictly anaerobic, spore-forming, Grampositive rod Clostridium botulinum. BTX can be differentiated serologically into 8 types. Recently, botulinum toxin type A (BTX A) has been recognized as an agent that can be used in the treatment of focal dystonias, including blepharospasm, oromandibular dystonias, and spasmodic torticollis.

 

BTX A acts as a presynaptic neurotoxin that blocks neuromuscular transmission by binding to receptor sites on motor or sympathetic nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine. This inhibition occurs as the neurotoxin cleaves SNAP-25, a protein integral to the successful docking and release of acetylcholine from vesicles located within nerve endings. When BTX A is injected intramuscularly in therapeutic doses, it produces partial chemical denervation of the muscle, resulting in a localized reduction in muscle activity. This causes dose-dependent weakness or paralysis in skeletal muscle. The effect of BTX A can last from 3 to 6 months, and local paralysis is reversed chiefly by neural sprouting with reinnervation of the muscle. In addition, when injected intradermally, BTX A produces temporary chemical denervation of the sweat glands, resulting in local reduction of sweating.

 

The Food and Drug Administration (FDA) first approved BTX for use in focal dystonia in 1989. Following completion of clinical trials, the FDA approved BTX A use in treating cervical dystonias, primary axillary hyperhidrosis, blepharospasm, and strabismus. These clinical problems have been challenging to clinicians and generally treated surgically with poor results. BTX has been widely adapted for these applications because it provides a minimally invasive approach to treating these challenging clinical problems. One of the most popular and successful applications of BTX has been in the treatment of hyperkinetic facial lines.

 

BTX A is produced by Allergan and is supplied in 100-unit vials. One unit of BTX corresponds to the calculated median intraperitoneal lethal dose (LD50) in mice. Unopened BTX must be stored in a refrigerator (2º to 8ºC), and preservative-free normal saline is used for reconstitution. In general, 1 to 8 mL of saline is added to 1 vial, producing a concentration of 10 to 1.25 units per 0.1 mL. Once reconstituted, the effectiveness of BTX begins to diminish after 4 hours. Therefore, immediate administration of BTX is recommended. The recommended doses range from 5 units to 25 units per muscle. The cumulative dose of BTX treatment in a 30-day period should not exceed 200 units.¹

        

[Drsumitra]

There is a growing body of evidence that supports the use of BTX A as a treatment modality for various TMD. Several subcategories of TMD including bruxism, clenching, masseteric hypertrophy, recurrent dislocation of the TMJ, oromandibular dystonias, and chronic myogenous orofacial pain have been effectively treated with BTX. However, without FDA approval, using BTX for treatment of TMD (with the exception of oromandibular dystonia) is an off-label application.

 

BTX has become a treatment modality in many healthcare disciplines. Its effects are reversible, and administration is minimally invasive. Adverse side effects such as dysarthria and dysphagia are observed when overdosing occurs or the injection misses the target muscle and the medication diffuses into adjacent structures. In addition, this treatment can be expensive ($474 for a 100-unit vial; adding a professional fee can bring the cost to more than $1,100 for a therapy that lasts up to 4 months). For off-label application, insurance does not cover BTX injections. Injection of BTX A should be performed by a clinician with knowledge of its pharmacology and the relevant anatomy of the sites receiving the injection. Finally, Allergan offers a comprehensive manufacturer’s package insert, which includes FDA-approved use of the medication as well as contraindications for its use, such as hypersensitivity, pre-existing neuromuscular disorders (eg, muscular dystrophy), and dysphagia. Although there has been no fatal hypersensitivity/allergic reaction to BTX, severe dysphagia, which resulted in aspiration pneumonia and death, has been reported

        

[Author]

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