After your child hits puberty and when the skeletal (bony) discrepancy between the upper and lower jaws are determined to be too large for the braces alone to solve this problem, the help of an Oral and Maxillofacial Surgeon will be needed to perform a surgical correction of the jaws.
This process is referred to as Surgical Orthodontics, which entails two specialties working together to solve the complex problem. First of all, the age of commencing the surgical orthodontics is at the end of the skeletal growth; as the patient gets closer to the skeletal maturity. This, of course differs from patient to patient. On average, the skeletal growth is reached in girls before the boys, and is usually around the age of 18 years old.
There are 3 ways that we can check that growth has been completed:
- Height Measurement.
- Lateral Cephalometric X-rays.
- Hand-Wrist X-rays.
Within a period of 6 months, if the patient’s height has not increased, this would be an indication that the growth has been completed. Yet, this fact alone is not sufficient to conclude that the growth is done. Another important measurement is to take two lateral cephalometric x-rays, at least 6 months – 1 year apart, and superimpose them on each other to see the changes in the facial bony structures. If no changes can be seen in the position of the upper and lower jaws, this would be a second indication that the growth is over. Again, this is only part of the puzzle, and we have to be absolutely sure that the growth is done before starting the treatment or considering surgery. The third and final factor when evaluating growth is the closure of the suture of the growth plates in the hand. We can evaluate this by taking a simple hand-wrist x-ray to ensure that the growth plate has closed and the growth has stopped. As Orthodontists, it is our role to ensure that all the 3 factors have been met and achieved. Yet, there is a small chance that growth might still continue even after the height, the lateral cephalometric superimposition and the hand-wrist x-ray have been all checked. We have to be skeptical!
Assuming that growth has been evaluated, when we are ready to start the surgical orthodontic treatment, the process is broken down into 3 phases:
- Pre-Surgical Orthodontics.
- Actual Surgery.
- Post-Surgical Orthodontics
The Pre-Surgical Orthodontic Phase is when we start the comprehensive fixed appliance therapy to prepare the teeth for surgery. The idea is to put all the teeth in their proper position in each jaw separately; this is called “decompensation”. The idea is that we align the teeth in their respective arches and the surgeon will correct the jaw position with the surgery. This Phase can last anywhere from 6 to 24 months, depending on the severity of the case. There will be multiple visits, where the Orthodontist will place brackets, bands and wires. They will be changed according to the need of your child on a regular basis. As we get closer to the end of the First Phase, i.e. “Pre-surgical Orthodontics”, we will need to take alginate impressions “Molds” of your child’s teeth to make sure that they are ready for the next phase, which is the surgery! One important point during this phase is that if the patient has third molars, they need to be extracted 6 months prior to the surgery. This is to ensure that we give the body enough time for the bone to heal around the extraction areas; so they do not act as weak stress points during the surgery. The surgical hooks will be placed on the archwires one month before the surgery.
The Second Phase is the actual surgery itself. Once the patient is ready for the surgery, he or she will be referred to the Oral and Maxillofacial Surgeon for final evaluation of the surgery. The Orthodontist will need to communicate directly with the Surgeon to discuss the details of the surgical plan; so that we can achieve the best possible outcome. They will decide together whether one or two jaw surgeries will be required. They will also discuss the amount of movement and the direction of movement of the bony structures. You can find more details about the nature of the surgery, what to expect, and the specific instructions here if you go to the surgery’s page. One important point to remember here is that your child will go into the operating room with the braces on; and they will not be removed before the surgery.
The Third Phase is the “Post-Surgical Orthodontics”. This is the final phase and on average would last 4-6 months, if the preparation was done very well. During this Phase, we would monitor the healing after the surgery and guide the bite by using elastics to help achieve the best possible outcome. The final touches of the bite (occlusion) will be done by the Orthodontist and it might include changing brackets and wires depending on the need. At the end of this phase, the retention protocol (retainers) will be discussed with the patient to ensure that we maintain the result we achieved.
