Jaw Deformities Center

Welcome to the Jaw Deformities Center at Childrens Hospital Los Angeles.

Our interdisciplinary team includes leaders in the fields of nursing, psychology, genetics, orthodontics, oral/maxillofacial surgery and plastic/reconstructive surgery. This energetic collaboration enables us to analyze, diagnose and treat complex deformities of the cranio-maxillofacial skeleton. Within our world-class center, we see patients from throughout Southern California and the United States, as well as internationally.

The Jaw Deformities Center treats a broad spectrum of pediatric patients with jaw deformities, including newborns with respiratory difficulties the result of a small lower jaw, adolescents with obstructive sleep apnea and craniofacial deformities, as well as teenagers with growth disturbances of the jaws. We take pride in providing today’s most advanced care in a compassionate manner.

COMMON QUESTIONS

What is orthognathic (jaw) surgery?

Othognathic Surgery comes from Greek words “Orthos” meaning straight and “Gnathos” meaning jaws. Because moving the jaws also moves the teeth, orthognathic surgery is usually performed in conjunction with orthodontics so that the teeth are in proper position after surgery. Orthognathic surgery helps restore a functional occlusion (alignment of the teeth of the upper and lower jaws when brought together) and proportionality to the facial skeleton. Initially, an orthodontist will level, align and coordinate the dental arches so the surgeon can reposition the jaws with corrective surgery. The objective is to correct the malocclusion and to achieve harmonious facial symmetry in an esthetically pleasing manner. Patients will have an improved ability to chew, speak, and breathe while achieving skeletal as well as soft tissue proportionality.

Who needs orthognathic surgery?
Patients who can potentially benefit from orthognathic surgery include those with a developmental skeletal dyspalsia, which is an improper bite (malocclusion) due to jaws that have grown disproportionately. Jaw growth is a slow and gradual process, and in some instances, for unknown reasons the upper or lower jaw may not grow in a proportionate manner. A majority of these children have been seen by an orthodontist and have been undergoing therapy to help correct the bite; the orthodontist can usually correct the bite if the malocclusion is purely dental in origin.

However, if the malocclusion has a skeletal component, then the bite may be off due to disproportionate jaw growth and will require orthognathic surgery in conjunction with orthodontic treatment. One typical case is a healthy 17-year-old child who has been in braces for a few years and still has a malocclusion. Such children will benefit from correction of the skeletal discrepancy to help achieve a normal occlusion as well as facial symmetry,

Children born with a cleft lip or palate also may require orthognathic surgery. These children usually have the cleft lip repaired at three months of age and the cleft palate repaired at nine months. They usually also require correction of an alveolar cleft in the eight-11-year range. Because of the multiple surgical corrections during childhood, these children usually experience an element of jaw growth disturbance that will require surgical correction. This correction is usually done at 16-18 years of age.

Other syndromes/conditions can lead to improper jaw growth. The most common conditions include Hemifacial Microsomia, Treacher Collins Syndrome and Pierre Rubin Sequence. These complex conditions may hinder skeletal growth and can lead to significant deformities.

Improper jaw growth not only contributes to difficulties with chewing , speech and oral health, but it can lead to an unnatural appearance that has psychosocial implications.

The diagnosis and treatment of developmental skeletal dysplasia , regardless of the origin, require an interdisciplinary team to diagnosis, develop a treatment plan and treat the underlying growth disturbance.


What do “occlusion” and “malocclusion” mean?
The upper and lower jaws normally meet in a harmonious manner that is called normo-occlusion or class 1 occlusion. A malocclusion is when the upper and lower teeth do not meet appropriately. Malocclusions that are dental in origin can be corrected with orthodontics. Malocclusions that are skeletal in origin are usually due to developmental skeletal dysplasia and require surgical intervention. The most common developmental skeletal dysplasia is open bite, over bite and under bite. An open bite makes it very difficult to chew and brings the lips together. An under bite is a class 2 malocclusion where the lower jaw is behind the upper jaw. An over bite is when the lower jaw is more anterior that the upper jaw, known as a class 3 malocclusion.

Antierior Open Bite	Under Bite	Over Bite
Diagrammatic representation of an anterior open bite. As can be seen the teeth do not come together in the front and thus the name “open bite”. An open bite is usually accompanied by lip incompetence, which is an inability to close the lips at rest. The correction of an open bite usually requires surgery of the upper and/or lower jaw. An orthognathic work up is indicated to determine the extent of surgical intervention.	Diagrammatic representation of a patient with an under bite or retro-gnathia.  This is a class II malocclusion.  With this developmental skeletal dysplasia, the mandible is positioned too far posteriorly in relation to the maxilla.  The correction of retro-gnathia usually requires moving the mandible forward. Sometimes the chin needs to be advanced as well (genioplasty) in order to obtain optimal occlusion and facial profile.	Diagrammatic representation of an “over bite” or prognathia.  This is a class III malocclusion.   This developmental skeletal dysplasia may be due to either the maxilla being too far posteriorly or the mandible is too far anteriorly. This condition can be treated with moving the upper jaw forward, moving the lower jaw backwards, or a combination of both procedures.  Once the ideal occlusion or bite is achieved, the chin can be moved anteriorly or posteriorly as needed to achieve optimal facial profile aesthetics.

 
Is my child a candidate for orthognathic surgery?

Among the children and adolescents who may be candidates for orthognathic surgery:

• Neonates with obstructive sleep apnea who require distraction osteogenesis of the mandible
• Children with malocclusions or maxillomandibular growth disturbances. (Children with syndromic and non-syndromic conditions may have growth disturbances of the upper and lower jaws.)
• Adolescents with a previous history of cleft lip/palate or craniofacial syndromes/ sequences; we recommend evaluation for potential complex othognathic surgical intervention to correct the skeletal discrepancy
• Malocclusion may occur without any underlying syndrome. Most children requiring orthognathic surgery are healthy teenagers who, for unknown reasons, have an upper or lower jaw growth discrepancy. These children require traditional simple orthognathic surgery to correct the improper bite and achieve optimal facial balance.
• Only an experienced oral /maxillofacial surgeon or orthodontist can determine if your child will require orthognathic surgery. The surgeon and the orthodontist work closely together to determine the movements needed to help place the upper and lower jaws into a more anatomical position. A general dentist is also part of the overall team. He/she is responsible for optimizing your oral health before, during, and after the orthodontic and surgical treatment.
• The Jaw Deformities Center at Childrens Hospital Los Angeles provides unparalleled, comprehensive care utilizing nurses, psychologists, dentists, geneticists and surgeons; Our goal is to provide you and your children the best surgical intervention in a caring, family-focused environment.

What can I expect at my appointments?

The Initial Consultation
The initial surgical consultation will allow the surgeon to get a good history and examine your child. It will also allow you the opportunity to ask any questions that you may have. It is important for you to be well informed about your child’s treatment. This includes understanding the need and timing for pre-surgical orthodontics. We will then take the time to make sure you understand your child’s individualized orthognathic surgical plan.

The Second Consultation
During a second consultation, we will complete a thorough examination with facial measurements, digital photographs, x-rays, 3D analysis and dental impressions.

Pre-surgical orthodontics may be employed to move your child’s teeth into a position that will facilitate a good fit postoperatively. During this pre-surgical orthodontic phase of treatment, which usually lasts six-to-eight months, the patient will be wearing braces and will visit an orthodontist regularly for necessary adjustments and ongoing evaluation. If the patient still has his/her wisdom teeth or the teeth are too crowded, it may be necessary to remove certain teeth prior to beginning orthodontic treatment in order to make space for proper tooth movement.

My orthodontist says my child is ready for jaw surgery. Now what?

Once the pre-surgical orthodontic phase is close to completion, we will verify that your child’s overall skeletal growth has completed (usually is 16 –17 years of age for females and 17-20 years of age for males). At that point, he or she will be ready for orthognathic surgery. We will ask you to return for the pre-operative surgical workup to finalize a treatment plan for corrective jaw surgery.

This complex analyses includes:  

• Routine digital photographic analysis
• Radiographic analysis 
• Dental study models
• Facial proportion and bite analysis
• Computerized treatment planning with 3 D analysis 
• Simulation of the surgical movements on study models
• Splint fabrication

The information is collected and utilized to perform a “mock” surgery – where the surgeon actually performs the proposed operation on study models and on a 3D image to simulate the proposed movements.

Two Weeks Prior to Surgery
Most orthognathic surgery is performed in a hospital under general anesthesia. Prior to surgery your child will have a physical examination to ensure he or she is in good overall health. This final pre-operative visit will allow us to try in the splint that was custom-fabricated for your child’s operation. We will review the operation with you one more time to make sure you understand the events that will happen on the day of surgery. Any required lab tests will also be done prior to surgery.

After the extensive workup and simulation have been completed, the operation can proceed.

The Morning of Surgery
The morning of the operation, you will check into the hospital and complete your registration. You will be taken to the pre-operative check in where a registered nurse will complete your child’s paperwork and exam. Then the anesthesiologist will discuss the general anesthetic procedure to be used and answer your questions.

During Surgery
The surgery is performed by at least two surgeons, following the steps pre-planned on the models and using mathematical algorithms. The length of the operation depends on the complexity of the case and how extensive the movement of the jaws needs to be.

Orthognathic surgical procedures last anywhere from two to six hours, depending on the amount and type of surgery needed. In lower jaw surgery, the rear portion of the jawbone behind the teeth is separated and the tooth-bearing portion is moved forward or backward, as appropriate. In upper jaw surgery the jaw can be repositioned forward or backward or the jaw can be raised or lowered.

Certain movements may require the jaws to be separated into several parts, with bone added or removed to achieve the proper alignment and stability. Other facial bones that contribute to the imbalance may also be repositioned, augmented or reduced in size.

Lefort I   In a Lefort I operation, the malocclusion is an open bite. In this case, the posterior portion of the upper jaw that has grown disproportionately has caused the open bite. The Lefort I is done by making cuts in the upper jaw and removing the excess bone. This is done entirely from inside the mouth. The jaw is positioned in an anatomical position that will allow the lower jaw to rotate into a normal class 1 occlusion. The upper jaw is secured with titanium plates. The plates are very thin and imperceptible.

BSSO (Bilateral sagittal split osteotomy)   In a bilateral saggital split osteotomy (BSSO) surgery, cuts are made on the lower jaw, again all from inside the mouth, to allow the lower jaw to slide forward into a normal occlusion. As shown here, the malocclusion is a class 3, retrognathia. If the lower jaw is more prominent than the upper jaw, then the same operation can be used except the jaw bones will slide back backward into a normal occlusion. The BSSO operation sometimes requires making a very small two-millimeter incision on the skin of the face just below the ear. This small incision helps us place three screws into the jawbone on each side. The screws hold the bones in there new position. Again the screws are imperceptible.

Sometimes an orthognathic operation may require further augmentation of the chin. This can be accomplished with a sliding genioplasty. This allows the surgeon to make cuts on the chin portion of the lower jaw. All the cuts are made from inside the mouth and the chin portion is mobilized and positioned in a more harmonious position so the soft tissue can achieve proportionality. The chin point can be backward, forward, up or down. The chin is secured with small plates and screws that are virtually imperceptible.

What are the risks or potential complications from orthognathic surgery?
In general, orthognathic surgery is very safe and the overall satisfaction rate of patients is very high. However, as with any surgical procedure, certain risks and complications are possible. The decision to recommend surgery is not taken lightly; you and your surgeon will consider the risks, benefits and options available based on your child’s individual treatment plan before you consent to surgery. The risks include, but are not limited to, the following:

1. Swelling: Post-operative swelling should be anticipated and will vary based on the extent of the operation. The post-operative swelling will peak around 72 hours after the operation. By day four, the swelling will start to dissipate. Improvement will continue until the swelling subsides which may take three-to-four weeks.
2. Nausea and vomiting: Post-operative nausea and vomiting may occur as a side effect of general anesthesia. We take pre-emptive measures to help minimize nausea/vomiting. Your child will receive intravenous medications that help decrease nausea pre-operatively, intra-operatively and post-operatively. Nausea usually dissipates by the second day after surgery.
3. Discomfort: The discomfort following orthognathic surgery is usually mild and is mostly attributed to post-operative swelling. We take pre-emptive steps to make sure that your child is comfortable after surgery with pain management medications and techniques.
4. Minor bleeding: Since most of the surgery is done from inside the mouth, there will be some mild oozing of blood from the mouth or nose. We will take steps to minimize this effect by having your child sleep with the head of the bed elevated at 45 degrees for the first three-to-four days. We will give him or her nasal sprays to help keep the nasal cavities open. In the rare event that your child experiences excessive or prolonged bleeding after you return home, contact your surgeon immediately.
5. Loss or alteration of nerve sensation: Your child may experience a temporary alteration in sensation of the face, jaw, teeth and/or tongue. This occurs due to post-operative swelling and stretching of the nerves that may occur with movement of the jaws. As the swelling dissipates and the healing process continues, most sensation will return. Most individuals have functional sensory return by six months postoperatively and have no complaints. However, some individuals may experience permanent altered sensations, particularly in lower jaw operations if a nerve is transected (cut) or excessively stretched. If a nerve is transected intra-operatively, we will repair it to try to maximize potential return of sensation.
6. Infection: Post-operative infection is a possibility with any operation. We take steps to minimize that risk, including giving your child pre-operative intravenous antibiotics before surgery. Also, most patients are kept on antibiotics for four-to-five days after surgery to help minimize the risk of infection to the plates/screws utilized. In the rare event that a plate/screw becomes infected and has drainage, it may need to be removed.
7. Sinus complications: The LeFort operation requires manipulation of the maxillary sinus membrane. Sinus discomfort or congestion may occur after surgery. If needed, we will provide a decongestant. Most sinus symptoms subside within 7 days. We will ask that your child not fly during the first seven days
8. Injuries to adjacent teeth: All precautions are taken to avoid injury to teeth during orthognathic surgery. In the unlikely event that teeth are injured, then we will refer your child to our restorative dental team for care.
9. Relapse: Patients with a history of clefts are more prone to relapse. More complex operations have a higher risk of relapse. Because of our extensive history of treating complex craniofacial cases, we have developed an algorithm to help minimize relapse after surgery. This may require that a splint be placed on the teeth for six weeks to help maximize the opportunity to keep your child’s bite in an acceptable position. In a small subset of patients, further surgical treatment may be necessary.
10. TMJ (jaw joint) pain: After surgery, there may be inflammation and swelling in the jaw joints. This usually subsides by the first week. We will give your child an anti-inflammatory medication to help minimize these effects. Persistent abnormal function in the jaw joint has been reported; however, it is rare .
11. Prolonged recovery: Other complications, such as post-operative pneumonia or aspiration, are rare but can occur.

Recovering from Surgery

After the completion of your child’s surgery, your child will be brought to our post-surgery recovery area. Your child’s surgical team will check to make sure that he or she is stable in recovery. After that, your child will be transferred to our specialized recovery unit. He or she will be encouraged to start taking in fluids and slowly advance to pureed food. On the second post-operative day your child will be encouraged to get out of bed and walk. Once the food intake by mouth is adequate, intravenous fluids will be stopped. Your child should be ready to go home by the second or third day.

Post-operatively your child most likely will experience temporary swelling of the lips and cheeks, as well as a mild temporary numbness at the surgical sites; this will improve when the swelling dissipates.

Your child also may have mild sinus and nasal congestion, along with a sore throat for a few days. We will take all necessary steps to make sure the symptoms are controlled. You will be given a decongestant and nasal spray to help alleviate nasal symptoms, along with throat lozenges as needed.

The first three-to-four weeks are crucial for the jawbones to heal well. Limiting mobility at the surgical site is paramount to facilitate proper healing. Your child most likely will wear guiding elastics to help minimize bite forces and guide the bite to the new position. Some patients will require a period of complete immobilization of the jaws with elastic rubber bands.

Nutritional intake is important to help the healing process. The first three-to-four weeks will require a pureed diet. We will provide you a nutritional guide for your child. Most patients are able to return to school by the second postoperative week. However we ask that your child avoid strenuous exercise and contact sports for four-to-six weeks.

What follow-up appointments will my child need?
Your child will have a follow-up appointment with your surgeon two weeks after surgery to make sure that he or she is healing well. In addition, your child will need to continue seeing an orthodontist. Most orthodontists will remove the braces six-to-eight months after surgery. Your will continue to see your surgeon regularly for the first year to make sure that he or she achieves an optimal result.


Patient Examples/Orthognathic Surgery
We highly recommend you ask your othognathic surgeon to show you pre- and post-operative pictures of patients he or she personally has operated on. The surgeon should be able to show you a variety of pre- and post-operative pictures of maxillary and mandibular osteotomies (LeFort and BSSO). Below are a few of the many patients that we have operated on in the Jaw Deformities Center at Childrens Hospital. We would be happy to show you many more examples during your initial consult.

Example #1

18-year-old male who has undergone right ear reconstruction and wanted a more prominent lower jaw. His bite was normal. We performed a genioplasty (chin surgery) to help him achieve good facial balance.

Before Surgery	After Surgery
Weak chin/lower jaw	Improved chin projection

Example #2

18-year-old female with Hemifacial Microsomia and Vertical Maxillary Excess (VME). Her face and jaws grew with a crooked cant, her upper jaw was prominent and she had a “gummy” smile.

Before Surgery	After Surgery
“Gummy” smile Upper jaw has a cant Lower jaw has a cant Chin is deviated to the left	Upper jaw corrected/leveled Lower jaw corrected/leveled Chin repositioned to midline

Example #3

18-year-old male with developmental skeletal dysplasia. His upper/lower jaws
were too small with poor projection. For his malocclusion, he underwent a LeFort, a BSSO and a genioplasty for correction of his bite and to achieve better facial balance.

Before Surgery	After Surgery
Poor maxillary projection Poor mandibular projection	Significant correction Very good facial balance

Example #4

The 18-year old male below presented with developmental skeletal dysplasia.  His upper jaw was too small with poor projection and his bite was off.  We did a LeFort and advanced the upper jaw forward to correct the bite and achieve a more proportionate facial balance.

Before Surgery	After Surgery
Poor maxillary projection	Improved upper jaw projection

Pre-Op X-Ray for Example #4

 
Appointments

Jeffrey Hammoudeh, MD, is the director of the Jaw Deformities Center, the Division of Plastic and Maxillofacial Surgery, Childrens Hospital.

To request a consultation for your child, please contact the Jaw Deformities Center at (323) 361-2154.