Specialist in Orthognathic Surgery

Specialist in Orthognatic Surgery

(Dento Facial Corrective Surgery)

Eutrapio S. Guevara Jr., MD, FPCS

Prognathism (Babalu), Micrognathism (Atras ang Baba)

… trust your face to a facial plastic surgeon with extensive experience in maxillofacial surgery, facial cosmetic, plastic-reconstructive surgery

What is Orthognathic Surgery?
Orthognathic surgery is what an oral, maxillofacial or craniofacial surgeon does to reposition one or both jaws in the correction of a wide range of minor or major facial and jaw irregularities. In fact, moving the jaws also moves the teeth. Orthognathic surgery is usually done in conjunction with orthodontic treatment, so that the teeth are in proper position after surgery. In many cases, an enhanced facial appearance and a well balanced facial profile and symmetry can also result.

Who needs Orthognathic Surgery?
Today, through modern technology, a variety of producers are available to correct facial deformities. Among these facial deformities are Prognathism (prominent lower third of the face or mandibular excess) and micrognathism (retruded jaw) with associated malocclusion. A prognathic jaw occurs when the lower jaw is overdeveloped and protrudes out beyond the upper jaw. Majority of these patients have malocclusion meaning that their teeth are not properly aligned and that the bones of the upper and lower jaws are in excess of deficient to produce and aesthetic profile. In the Philippines, treatment and surgery for these kinds of deformities are still not so popular, that is why a lot of Filipinos in all walks of life can be seen hanging around with such facial disfigurement. They are what we commonly describe now as “Babalu” or “Walang Jaw”. Some would use their facial appearance in show business.

The following are some of the conditions that may indicate a need for orthognathic surgery:

Open bite (space between upper and lower front or back teeth when mouth is closed)
Unbalanced facial appearance (facial asymmetry)
Unequal growth of the jaws, injury or birth defects
Receding chin (Micrognathism)
Protruding chin (Prognathism- “babalu”)
Facial injury- old or mismanaged jaw fractures
Midfacial retrusion after surgery of Cleft Palate/Lip
Sleep Apnea (breathing problems- heavy snoring and difficult breathing)
Difficult chewing or biting food

How is Orthognathic Surgery Done?
In the past, these were just treated by dental surgeons by pulling out all the teeth thinking that these can be controlled by prosthetic dentures. Most of them think that this can be treated by purely orthodontic treatment mobilizing only the teeth but not the jaws. Repair of a protruding or recessed jaw is a major surgical procedure. It is performed in the hospital, under general anesthesia, and it takes anywhere from 2-6 hours. Before surgical treatment is undertaken, various work-ups are done such as Cephalometric evaluations, Panoramic x-ray of the jaws, dental model cast and cutting and photography. The cooperation between the orthodontist and maxillofacial surgeon serves as basis for the general acceptance of combined orthodontics and surgical treatment of jaw problems as the treatment of choice. In some occasions, prior to actual surgery, orthodontic treatment (pre-surgical orthodontics) is first done to facilitate actual occlusion during surgery. After surgery, final orthodontic tooth movement is usually necessary to fine-tune your bite.

The latest surgical procedures now are done without incisions of the skin of the face to expose the jaw in making the bone cuts but everything inside the mouth. During the last decade, closure of the mouth takes at least 6-8 weeks and the patient is fed through the nasogastric tube inserted through the nose. With the latest technology of internal rigid fixation in maxillofacial surgery to stabilize segments of the jaw, closure of the mouth is only 5 days. Hospitalization is decreased to at least a week, the patient can eat through the mouth in a week time, and the possibility of relapse and complications has been avoided.

Medialization Genioplasty (narrowing)
Achieving a Feminine and Slim Lower Face

Before

Before

After

Narrowing genioplasty, either as a single procedure or in combination with mandible reduction, makes the lower face appear slender and produces a more feminine contour.

After

Mandibuloplasty
Reduction of Angle/Body by Osteotomy/Masseter

ANGLE AND BODY REDUCTION: BETTER IMPROVEMENT

After

Before

After

Correction of Prognathism with Le Fort 1 and Mandibular Reduction

Before

After

Long Face Syndrome

Gummy Smile (Horse Face)

Maxillary Hyperplasia

Secondary Correction of Cleft Lip-Nose with Orthognathic Surgery

Asymmetric Jaw: Orthomorphic Surgery alone

Before

After

Asymmetric Jaw with Prognathism:

Combined Orthognatic and Orthmorphic Surgery

Before

After

Before

After

Mandibular Asymmetry Correction:

• Ramus Osteotomy, Right

• Saggital Split Osteotomy, Left: Short Ramus

• Transverse Sliding Osteotomy: Chin

• Lateral Augmentation with Medpore (chin implant) after Mandibular rotation to the right with Osteotomy Chin Rotation to the right

After

Before

3D Printed Polycaprolactone

Mentoplasty (Chin Augmentation) - Sliding Osteotomy … Without Malocclusion

Before

After

Mandibuloplasty

Augmentation- Angle of the Jaw using 3D Printed

Polycaprolactone/Tricalcium phosphate instead of Iliac bone graft

Bone Graft (Iliac)

Coronal Incision Approach

Malar Augmentation

Forehead (Frontal) Bone Contouring and Brow Lift via Coronal Incision,

1992, Cesar Ramirez, MD

Mandibuloplasty- Slender Lower Face
Reduction of Angle/Body by Ostectomy/Masseter

Techniques

Mandibuloplasty
Reduction of Angle/Body by Osteotomy/Masseter

X-RAY STUDIES

Mandibuloplasty- Slender Lower Face

Reduction of Angle/Body by Osteotomy/Masseter Trimming

Mandibuloplasty
Reduction of Angle/Body by Osteotomy/Masseter

Removal of first maxillary premolar

Removal of first mandibular premolar

Before

After

Before

After

Bimaxillary Protrusion: Orthognathic Surgery
with Mandibuloplasty (Ostectomy)

Osctectomy Site

Before

After

Malar Reduction: Osteotomy - Shaving

Before

After

Before

After

Malar Augmentation Using 3D Printed PCL (Polycaprolactone)

Before

After

Malar: Midfacial Rejuvenation

Malar Fat Pad Suspension - Malar accentuation/enhancement with

3D Printed Polycaprolactone (PCL)

1. Revision Augmentation Rhinoplasty (Silicon removed)

- combination GoreTex and PCL sheet

2. Revision Malar Augmentation (Silicon removed)

- Midfacial Rejuvenation using Polycaprolactone (PCL)

Proper Technique for Transcolumellar Incision

Discussion: The Downsides of Open Rinoplasty

The Disadvantages of the Open Approach:

Transcolumellar scar and columellar flap skin loss

Correctly placing a staggered incision across the columella just anterior to the flare of the feet of the medial crura
Leave the continuity of the medial crurae intact
Undermining 5mm below the inferior segment of the incision for proper leveling of wound closure
Meticulous suturing

Securing and suturing a multitier (multilevel) shield graft with backstop graft

Adapted from: Prof. Yong Ju Jang, MD, PhD., Seoul, Korea

Augmentation Rhinoplasty

Combination of GoreTex (e-PTFE) or Silicon Implant, with Cartilage Graft for Tip Plasty

Before

After

After effect of Nasal Base Reduction

Mentoplasty (Chin Augmentation) - Implant (Medpore) … Without Malocclusion

Before

After

With Nose Lift

Submentoplasty
Liposuction and GoreTex for Neck Rejuvenation with Chin Augmentation

Before

After

Mandibuloplasty
Reduction of Angle/Body by Osteotomy/Masseter

Before

After

Mandibular Split Ostectomy
Medialization Genioplasty (narrowing)
Achieving a Feminine and Slim Lower Face

Medialization Genioplasty (narrowing)
Achieving a Feminine and Slim Lower Face

Before

After

Bimaxillary Protrusion

B

Surgical Technique

A

Diagnostic Work-ups: Orthomorphic and Orthognathic Surgery

A.

B. Cephalometric Radiography with or without tracings (Computerized)

C. 3D CBCT & 3D Printing Model

D. 3D Digital Computer Graphics Simulation Surgery (by navigation)

E. CT-Scan and 3D Reconstruction Imaging (CBCT)

F.Pre-fabricated model Cast of the dental occlusion with Articulator (3D Printed-Virtual Surgical Planning)

G. Steriolithography model cast of the Facial skeletal Structures (3D Printed-Virtual Surgical Planning)

H. Photography (Pre and post) documentation

I. Physiological counseling

Panoramic Radiologic Study

Prognathism- Class III Malocclusion
Mandibular Excess with Midfacial Retrusion

Before

After

Asymmetric Jaw for Orthognathic Surgery or Orthomorphic Surgery or Combination?

Orthognathic surgeries alone, however, often are unable to resolve contour defects arising from asymmetric growth disparity.

The changing perceptions of facial beauty and the emergence of utilitarian oncepts of attractiveness endows a particular urgency for the orthognathic surgeons’ repertoire to include orthomorphic corrections.

- Paul Salins, MDB, JOMS, 2008