Are there alternatives to corrective jaw surgery ?

About half the number of patients who see me for a consultation on corrective jaw surgery are not sure if they need surgery. For this group, the first question that they ask is whether I think they need surgery. The other half has already done their research, they may even have consulted some other surgeons, and they have a fairly good idea what they need and want. This latter group knows that corrective jaw surgery can help them achieve their aesthetic as well as functional goals. However, they also know that the surgery is no walk in the park and they are often looking for alternatives that are less invasive and has a lower morbidity and downtime.  What are the alternatives?

First, the basic prinicple is to establish what the treatment objectives are. This is often a rather difficult part. Many patients with dentofacial deformities are a bit self conscious and getting them to articulate their wishes takes a bit of coaxing. Some find it awkward and embarrassing and they prefer that I tell them what I think is wrong with their face and recommend a treatment plan. I usually try my best to avoid this as each person's idea of aesthetics is different and I do not want to impose my own aesthetic sense on a patient at this stage of the evaluation. Inevitably, my own aesthetic preference will be brought into play at some stage but I want to know what the patient's primary motivation for seeking treatment is first. 

Once we establish the treatment objectives, we can explore the various treatment options. For patients whose dentofacial deformities are severe and treatment objectives uncompromising, orthognathic surgery may be the only way to go. In the Asian context, more often than not, we are dealing with excessive growth of the jaw bones rather than insufficient growth. Once the excessive bone is formed, the only way to corrrect it is to reduce it and that means surgery. For patients with an "underbite" problem, ie the lower jaw protruding forward of the upper jaw, surgery is the only way to correct it fully. Similarly, in cases of severe gummy smile, surgery is the only way to remove the excessively developed upper jaw to repositioned it into a more aesthetically pleasing position. Dentofacial deformities that are due to deficient jaw bone development can be managed with other treatment modalities.

1. Orthodontics

Orthodontics can be use to mask the deformities. For example, if the upper or lower jaw is excessive, teeth at the back of the mouth can be extracted to create space for the braces to pull the front teeth backwards, in an attempt to change the facial profile. Orthodontic treatment in such situations is primarily to camouflage the deformity without actually changing the basic bone structure. This is suitable for patients whose deformity is not very severe and treatment objectives are not very exacting. In considering orthodontic masking instead of surgery, the patient must understand that the final results may be compromised aesthetically as well as functionally. The change in facial appearance may not be what the patient expects and the bite of the teeth may not be optimal due to the unnatural tilting of the teeth to camouflage the deformity. However, without surgery, one can circumvent the risks and potential complications of surgery. A word of caution to those who are considering this is that once extraction orthodontics are done and if you are not happy with the results, it is not easy to go back to a surgical option. This is especially so when teeth are extracted as part of the orthodontic treatment. The reason is that orthodontic alignment of the teeth in preparation for orthognathic surgery is usually done in the opposite direction to orthodontic camouflage. 

For the younger patients with growth potential, dental orthopedic devices like headgears as well as functional orthodontic appliances can help to redirect growth the minimize the excesses and stimulate growth in the deficient areas. 

2. Facial implants

Facial implants such as cheek implants and chin implants can be used to augment the parts of the face where there are deficient growth. Deficient growth of the upper jaw can be camouflaged by surgically inserting malar implants and paranasal implants to make the midface more prominent. Similarly, such implants do not change the basic skeletal structure but merely increase the projection of the face in the areas where they are placed. Another common implant that replaces the need for orthognathic surgery is the chin implant. In patients with "weak" chin, chin implant achieve the same aesthetic improvement than the traditional genioplasty. 

The main downside of such an approach is possible infection of the implant in the future, as any foreign object placed in the body will attract more bacteria than the body's own tissue. Furthermore, for chin implants, being directly sandwiched between a powerful mentalis  mucsles and the chin bone, there is a possibility of the chin implants causing resorption of the underlying bone.

3: Dermal fillers

 Dermal fillers are currently all the rage as a form of non invasive aesthetic treatment. Most commonly, dermal fillers are used to fill up wrinkle creases and adding volume to the facial tissue. When used in large quantities, dermal fillers can be used as a replacement for facial implants. The main advantage of dermal fillers is that they are injected into skin with no surgery involved. However, because the filler is only skill deep, sometimes, there may be bumps on the face that will take some time to dissipate and even out. The advantage of fillers is that it is temporary and will dissolve away in a couple of years. However, that is also its disadvantage as repeat injections will be needed to maintan the appearance.

Ultimately, whether good old orthognathic surgery is for you or not depends on your treatment objectives and how firm your needs and desires are. I often advise patients that if they are not ready, do not do something just for the sake of doing it. It is important to understand that the results are always best when a single treatment is done than when a series of treatment in ascending order of complexity is done. Prior treatment often undermines the best results of orthognathic surgery. Only when you have decided that you will definitely not undergo orthognathic surgery should the options be explored.