Aesthetic Orthognathic Surgery

Aesthetic Orthognathic Surgery from HMP on Vimeo.

In this video, Dr. Aziz, DMD, MD, discusses best practices, surgical planning, and more regarding aesthetic orthognathic surgery.

Dr. Shahid Aziz:  My name is Shahid Aziz. I am a professor of oral and maxillofacial surgery at Rutgers University.

Question 1: What are the goals of the patient consultation in aesthetic orthognathic surgery. Are there best practices for the patient consult you would recommend?

Dr. Aziz:  From the standpoint of aesthetic orthognathic surgery, orthognathic surgery has a major aesthetic component to it. Originally, it was surgery that was done to correct skeletal malocclusions, meaning underbites, overbites, open bites, things like that.

As we've evolved in our sophistication in treating and diagnosing skeletal malocclusions, we now focus not just on the bite but also the aesthetic component. When you're moving the upper or lower jaw, in whatever direction you decide to, it does have an impact on the facial aesthetics.

One of the things that I like to do during my consultation is not just to discuss the malocclusion, but also discuss the aesthetic impact on moving the chin, moving the upper jaw in relation to how it affects the nasal tip.

Is there a rhinoplasty the patient could benefit from? A genioplasty the patient may benefit from? Malar implants, cheek implants, things like that. What most importantly needs to be asked is what the patient is looking to do. What their hopes are and what they want to achieve by doing orthognathic surgery. It's really important that the surgeon and the patient are on the same page.

Question 2: Can you speak to the importance of understanding basic concepts of occlusion in orthognathic surgeries?

Dr. Aziz:  Occlusion is the basis of orthognathic surgery. You need to have an understanding of occlusion to perform orthognathic surgery, meaning you need to understand how teeth come together.

That is important because orthognathic surgery was designed and is a surgical technique developed to correct malocclusions that are skeletal in nature. One must understand occlusion to perform orthognathic surgery correctly.

Question 3: Do you perform rhinoplasty/genioplasty in conjunction with upper/lower jaw surgeries? How do you stage these?

Dr. Aziz:  I will perform genioplasties and rhinoplasties in conjunction with orthognathic surgery. Again, this is something that is discussed in conjunction with the patient.

More commonly are genioplasties, the rhinoplasties, at least in my practice. Again, when you're moving the facial skeleton, it is going to affect the position of your chin it is going to affect potentially your nose. Doing those cosmetic procedures in conjunction with maxillary and mandibular osteotomy can often provide the patient with a great aesthetic outcome.

As far as staging these, genioplasty, it's fairly straightforward. I like to reestablish the occlusion, move the maxilla, move the mandible, and then do the genioplasty last. Because I've moved everything and while I've planted preoperatively, I can also assess the chin on the table as well.

Rhinoplasties are a little harder. The reason that they're a little harder is because often you have to switch the endotracheal tube. Most orthographic surgeries have a nasal intubation and that obviously could get in the way of your rhinoplasty. You need to figure out the order in which you're going to do things.

When I have rhinoplasties is in conjunction with orthognathic surgery. I'll do the rhinoplasty component first with an oral to and once that's completed, I may switch to a nasal tube or vice versa. I may do the nasal tube first so I can do the orthodontic surgery and then go back and place an oral tube so that I can do the rhinoplasty.

One has to think about the process and work with your anesthesiologist as far as the sequence of how you want to intubate.

Question 4: Do you utilize virtual surgical planning? How do you plan these surgeries considering the soft tissue changes related to bony movements?

Dr. Aziz:  Virtual surgical planning is becoming the standard of care in planning orthognathic surgery. I use VSP, virtual surgical planning, for every case that I perform in orthognathic surgery and beyond and facial reconstructive surgery, etc.

Virtual surgical planning allows me to be much more precise and allows me to get a better understanding of the surgery that I'm doing. It allows me to create custom rigid fixation plates. It allows me to create splints, custom splints, etc., that helps streamline the surgery.

I think that virtual surgical planning is a major component of planning orthognathic surgery and it's replacing traditional model surgery. As far as soft tissue considerations, that's the one real limitation right now with virtual surgical planning.

Because most of the planning software that is out there doesn't do justice to the soft tissue changes that can occur from doing maxillomandibular osteotomy and moving the upper and lower jaws.

That is a limitation with virtual surgical planning. Like anything else, technology is evolving. We'll have at some point a much more reliable virtual surgical planning for not just the facial skeleton but also the soft tissue associated.

Question 5: What is your minimum age requirement for patients to be able to undergo these surgeries?

Dr. Aziz:  Age in orthognathic surgery, and that's a good question because there's a little bit of controversy with that in the oral maxillofacial surgery community and the orthodontic community. For girls, it's a very simple rule of thumb. It's based on menarche.

Some people like to wait two years postmenarche before doing any type of orthognathic surgery, I tend to wait a little longer, about three years postmenarche for orthognathic surgery. At that point, I'm fairly certain that for girls, they have stopped growing.

For boys, it's a lot harder to predict, obviously. The ways to predict traditionally were using hand-wrist films, but those were found to be not as reliable as it was once thought to be.

For me, I like to do orthognathic surgery in boys when I see that they haven't changed their shoe size in a while, when I see them developing facial hair and hitting puberty. Those are times when I feel more comfortable doing orthognathic surgery on males. That being said, sometimes you have to do it sooner than you want to for a variety of reasons.

They've been in orthodontics for a very long time and keeping them in orthodontics is starting to damage the teeth, there may be insurance issues with insurance coverage that make us do these things ahead of time.

In general, girls, I like to wait three years postmenarche. Boys, I like to make sure they at least hit puberty, start shaving, and have stabilized shoe sizes.

Question 6: What key takeaways would you like to convey to your colleagues regarding performing orthognathic surgery?

Dr. Aziz:  Orthognathic surgery is my favorite subspecialty of maxillofacial surgery. The reason for that is you have a profound impact on these kids. You'll take a kid with a severe class II or class III malocclusion, who's very shy, and you'll see they go through braces, they have surgery, and then you'll meet them a year or two post surgery and you'll see that they're completely different people.

They're much more outgoing and much more confident. The psychological impact of orthognathic surgery is profound. That's what makes it all worthwhile. All the years of training and studying, make it worthwhile.

I will tell you that the most important thing for somebody who's going to be doing orthognathic surgery is to, one, know your patient. Be on the same page with your patient as far as what they want. You need to make sure that you can fulfill that. Understand occlusion. Very, very important.

Then have a good rapport with your referring orthodontist. Again, you're on the same page. You're part of the team, you and the orthodontist, for treating this patient for orthognathic surgery. You need to be on the same page as the orthodontist. If you follow those simple steps, you can be very successful and have a very good outcome.