When I first started doing orthognathic surgery twenty years ago, patients are mostly referred by orthodontists. Back then, patients who have a dentofacial deformity often seek the help of an orthodontist first. This is a natural course of action as most people are afraid of surgery. If braces solve the problem without surgery, all the better. However, in recent years, there is a noticeable increase in the number of patients seeking cosmetic jaw surgery without going fhrough an orthodontist first. Perhaps, the internet has made more information readily available and more patients are able to determine that they need surgery. Or perhaps, it is also a reflection of the instant gratification culture that we have now. Regardless, cosmetic jaw surgery has also developed to the point where we have a good understanding of the anatomy of the jaw and the physiology of healing that we are able to, in some cases, do the surgery first, and then braces post-surgery. Some patients, especially working adults, would like to do away with braces altogether as wearing braces for two years is not quite acceptable in their jobs. There are some circumstances where this is possible, though the results would not be as good as with braces.
What kind of jaw deformity can be treated surgically without braces?
When we do an aesthetic assessment of the face, we look at proportions and symmetry in all directions, ie frontally, profile and from the top and bottom. Such data is tempered with social and cultural norms as welll as the preference of the patient. Deformities that can be treated without braces are mostly due to disproportions in the vertical plane. A condition that we commonly call vertical maxillary excess (VME). Unlike horizontal discrepancies of jaw size which is readily recognized by patients themselves, VME is less readily apparent. Yet, this is very common amongst patients of Chinese and Malay descent, which makes up a huge part of the SIngapore population. The presenting complaint of these patients is usually that they find their front teeth too protruding and that they look like Bugs Bunny. Many of these patients undergo orthodontic treatment with extractions of four premolars to create space to pull back the front teeth. This reduces the degree of horizontal projection of the teeth but does little to address any vertical excess.
Vertical access is primarily due to excessive growth of the tooth bearing part of the jaw bones. Other than prominent front teeth, a VME patient also has a gummy smile and a long face. Some even have an open bite ie the upper and lower front teeth cannot touch.
Why vertical deformities can be done without braces?
First, I must emphaize that while it is possible to do corrective jaw surgery for vertical deformities without braces, it is not ideal. The best treatment plan will still involve orthodontic treatment to align the teeth. This is because of the fact that the objective of the jaw surgery is to move the jaws into the optimal position for facial aesthetics. The degree of movement is partially limited by the teeth position as we also need to take function into consideration. No point having a well proportion face but your teeth can bite on anything right?
In most VME cases, the teeth alignment and occlusion is usually quite good to start with. Unlike horizontal jaw disproportions like overbite and underbite cases, where the teeth are usually crowded and tilted, in VME cases, there is usually sufficient bone to house all the teeth, thereby reducing the incidence of crowding, and because the horizontal growth of the upper jaw is proportional to that of the lower jaw, there is no tilting or what we call "dental compensation" of the teeth. Such a situation presents an ideal case of doing surgery without braces.
How is it done?
Again, I need to stress that every case is different. However, there are some general principles. In the majority of cases, it will be a double jaw surgery.
For the upper jaw, we need to reduce the vertical height as well as set the front segment of teeth backwards. This is done by down-fracturing the upper jaw and then cutting off a pre-determined amount of bone vertically. In addition, there is also a need to extract two premolars and divide the upper jaw into three or four parts and then piecing them together into a pre-fabricated splint and then re-fixing with titanium plates and screws.
For the lower jaw, extraction of two premolars is also usually needed and the front segment of the tooth bearing part of the jaw is detached and repositioned backward to close the space left by the extracted teeth. This segment is also fixed using titanium plates and screws.
So, what's the downside of not having braces with jaw surgery?
Braces is needed to fine tune the position of the teeth, which is an integral part of an aesthetic and pleasing smile, as well as good biting efficiency. Wihtout braces, we cannot achieve the optimal aesthetics and function. In addition, it also increases the degree of positional change that often occur after corrective jaw surgery as the bite will not be as stable and that can cause deviation to the jaw position before healing is complete.
What cases are not suitable for surgery without braces?
Most of the underbite and overbite cases, where the source of deformity is due to horizontal discrepancies in jaw size, are not suitable, This is because these discrepancies in jaw size do not happen overnight. They take place gradually over a few years during the adolescence. As one jaw grows disproportionately more than the other, the teeth are carried further apart due to the growth. The teeth, however, are "clever" as they automatically compensate for the difference is growth rate of the upper and lower jaws by tilting themselves to achieve contact with the opposing teeth so as to maintain some degree of chewing efficiency. As such, surgery to reposition the jaws in such cases, will result in these "compensated" teeth being out of occlusion as they were adapted to the old position of the jaw bone. However, surgery can still be done before the braces though, post-operatively, orthodontic treatment is absolutely eseential.
Even amongst the VME cases, there are some that may not be suitable for a orthodontic-free treatment plan. If there is significant crowding of the teeth, we will not be able to achieve a stable bite with surgery alone.
Should I do it?
You should discuss with your dentist and orthodontist. But more importantly, you must discuss with your maxillofacial surgeon as he is the one that's going to operate and he will be able to tell you what he can or cannot achieve, and the pros and cons of each options. Don't be afraid to get a second opinion as cosmetic jaw surgery is fairly invasive and you should do your due diligence before committing. When I sense any uncertainty in my patients, I usually advise them to seek a second opinion. Sometimes, they may be more comfortable with the next surgeon they see and proceed with his treatment plan while some may come back after the second opinion. Cosmetic jaw surgery is an elective procedure and there is no absolute right or wrong way of doing. Ultimately, choose the surgeon and the treatment plan that you are most comfortable with.