Who calls the shots in orthognathic surgery- orthodontist or surgeon?

Many conditions require multi-disciplinary management. For example, ischemic heart disease may require the expertise of the cardiologist and the cardiothoracic surgeon. In the same, way, dentofacial deformities require the expertise of the orthodontist and the maxillofacial surgeon. The best outcome is achieved when surgical and non-surgical options are considered, balancing the treatment objectives and the risks involved. However, very often, the treatment plan depends on who is primarily in charge of the treatment planning.

In my practice, some patients are referred by their orthodontists while others come directly, without an orthodontist’s referral. Orthodontists are trained to assess the craniofacial skeletal structure. They understand the growth and development of the facial skeleton and how the various malocclusion of teeth and disharmonies of jaw relations come about. However, orthodontics as a treatment modality has a limited spectrum of disharmonies that it can manage. If the patient’s primary concern is teeth alignment and occlusion, orthodontic treatment alone may well be adequate. Orthodontic treatment can alter facial appearances by tooth movement because of the accompanying jaw bone remodeling. In younger children, orthodontic appliances can also alter growth of the jaws. For example, functional orthodontic appliances can help to slow down the elongation of the lower jaw while stimulating lengthening of the upper jaw in young children with an underbite tendency. Such orthodontic treatment involves growth modification and when done correctly on suitable patients, can eliminate the need for surgery. However, getting a young child to comply with complicated orthodontic appliances can be challenging.

For patients who have already developed a disharmony of jaw relation, orthodontic treatment alone can only achieve a partial resolution. If the degree of discrepancy is very minor and the patient’s primary goal is not a change of facial appearance, camouflaging the discrepancy by moving the teeth to compensate may achieve the patient’s goals.

However, for a patient who is seeking a change of facial appearance, orthodontics alone is not the solution. Very often, I see self-referred patients coming to me for surgical consultation after having done had orthodontic treatment, saying that they are not satisfied with the results achieved through orthodontics alone and want to have surgery to alter their facial appearance more. However, orthognathic surgery cannot be added on as an optional item after orthodontic treatment. For this group of patients, the orthodontic treatment that they have had must be reversed in order for surgery to be performed. This is because the objective of orthodontic treatment alone is diametrically opposed to orthodontic treatment in preparation for surgery.

For a patient who seeks to have significant facial changes such as correcting a concave facial profile, excessive gummy smile, facial asymmetry, etc, orthognathic surgery is needed. The decision must be made right at the start of pre-surgical orthodontic treatment and not at the end. For these surgical patients, the treatment objective is a change in facial appearance and the plan must put that front and centre. Sometimes, in such a team approach, there may be disagreements between the surgeon and the orthodontist due to their different training background. In such situations it is important to resolve the differences by revisiting the primary treatment objective. Sometimes, in the process of attaining the goals of facial appearance, the final occlusion of the teeth may have to be less than ideal.

This requires a common understanding between the surgeon and the orthodontist. I believe that all patients who decide to undergo corrective jaw surgery seek to have a change of facial appearance. If their primary objective is proper alignment of their teeth, there is no need to undergo surgery. One of the common disagreements is over whether a single jaw or a double jaw surgery is needed. In most cases that do not involve facial asymmetry, it is possible to achieve an ideal occlusion with a single jaw operation. However, in most of these cases, doing a single jaw operation will not achieve the desired facial appearance. Take for example, a patient with a severe underbite, where the lower jaw is protruding more than 10mm beyond the upper jaw. A normal bite can be achieved by either setting the upper jaw forward by 13mm or setting the lower jaw backward by 13mm. However, the former will give rise to an ape-like appearance while the latter will result in a flat face with no chin. This effectively replaces one facial deformity with a different facial deformity. A more harmonious facial appearance can be achieved by moving the upper jaw forward, by maybe 5mm, and setting the lower jaw back by 7mm, or any combination, depending on the preferred facial appearance determined by the patient.

Corrective jaw surgery needs to be planned with the end in mind. That objective has to be determined by the patient through detail consultations and treatment simulation with the surgeon. Ultimately, the patient must be the one calling the shots. Once the treatment objective is determined, the team can then formulate the treatment plan.