Cincinnati Center for Corrective Jaw Surgery

4 Types of Foods You Can Eat After You Had Your Wisdom Teeth Removed

indulge post-surgery

About 90% of people need to get their wisdom teeth removed. If you are a part of that 90%, you might be wondering what the steps are post-surgery. Taking it easy and getting a lot of rest is a key step to a quick recovery. Another big step is knowing what you can and can’t eat. Here is a list of foods you can indulge in post-surgery.

  1. Ice Cream: After having a minor surgery, it’s okay to treat yourself with a little sweet. The coolness will not only feel good, but it will also help sooth inflamed tissue. Try to avoid eating cones and flavors of ice cream with large chunks in them like chocolate chips and nuts.
  2. Soup: Soup is a great food to have on hand after your surgery. It provides protein and the broth is easy to eat. If you choose this brothy goodness, make sure you aren’t eating large pieces of vegetables and the temperature of the soup isn’t too hot.
  3. Mashed potatoes: Not only are mashed potatoes delicious, but they are easy to make and they really are the perfect post-surgery food. You can smother them with gravy, butter or sour cream. Top the meal with whatever sounds good to you, but make sure there aren’t large potato chunks you’ll have to chew. Another route you could take is mashed sweet potato. Top it with butter and cinnamon to take this savory treat to sweet!
  4. Smoothies (NO STRAWS): Smoothies are a great source to get all the nutrients your body will need. You can make different flavors with fruits and vegetables. Prepack your smoothie packs before you have your surgery so all you have to do is blend and enjoy. You could also add in different protein powders or vitamins to help your body. If you choose to make a smoothie, DO NOT USE A STRAW. Sucking on a straw could disrupt your healing process and create dry sockets.

These are just a few ideas of what you can eat post-surgery. There are a ton of other options. Get creative and indulge in the snacks you wouldn’t normally eat for your main course. If you have any hesitations or questions on what you can’t and can eat, call our office. We are happy to answer any questions you may have. 513-232-8989

5 Tips for Jaw Surgery Recovery

recovery tips

Orthognathic surgery, also known as “jaw surgery”, is used to correctly align an improper bite or jaw position. If you are thinking of undergoing jaw surgery, here are a few tips to help you with your recovery.

  1. Get Plenty of Rest
    A key to helping your body recover is to rest as much as you can. Find things to keep you entertained as you take it easy such as coloring, reading, or a new TV show. Keeping yourself entertained will help the time to pass faster.
  2. Stay on a Regular Schedule
    While resting is important, staying on a regular schedule will help you feel productive while you recover. As you begin to feel mobile, take short walks outside.
  3. Apply Heat and Ice
    Applying heat and ice regularly will help to combat facial swelling and reduce your discomfort. You will be the most swollen during your first week of recovery. Keep an extra ice pack in the freezer so you always have one ready to go.
  4. Meal Prepping
    Meal prepping before your procedure will help you in the long run. During recovery, you may not feel like cooking. Having pre-planned meals will let you easily prepare nutritious meals with minimal effort. Some great meal ideas to prepare ahead of time are smoothies, soups and homemade juices.
  5. Stay Hydrated
    Drinking enough water is important for allowing your body to heal and for avoiding dehydration. You might have to remind yourself to drink water so keep a water bottle handy and sip throughout the day.

Corrective jaw surgery recovery can seem like a long process, but once your jaw has healed, you will have a more healthy, attractive and functional jaw. If you believe that you would be a good candidate for jaw surgery, contact our office for a consultation at 513-232-8989.

5 of Reasons You Shouldn’t Wait For Your Dental Implant

the sooner the better

You need a dental implant, but you are reluctant to get started. We understand that there is some hesitation and life gets in the way. However, here are a list of reasons as to why you shouldn’t wait.

  1. Stop your remaining teeth from moving. Your teeth help keep everything in place. When you are missing a tooth, and have a gap, your teeth will start to shift to fill in that gap. That could cause not only uneven teeth, but teeth that are harder to clean and, in the end, that cost you more to fix.
  2. Save Your Jawbone. When you are missing a tooth, your jawbone slowing starts to deteriorate and shrink away. The roots of your teeth keep the jawbone stimulated to maintain the bone mass. The longer you are missing the tooth, the more the bone will disintegrate, making the implant process more difficult.
  3. The appearance of your face. Living without a tooth can eventually change how you look, especially if you suffer from bone deterioration. The longer you go, your skin could begin to make your cheeks sag, which will make you look older than you are.
  4. The way you speak. When you are missing a tooth, it could make it hard to annunciate words, making you sound like you have a lisp.
  5. Your overall self-esteem. Getting a dental implant will allow you to feel like your normal self. You won’t have to worry about how you look or how you sound. The implant looks and feels like a normal tooth. No one will know that you have an implant unless you tell them.

These are just a few reasons as to why you shouldn’t wait to get your dental implant. If you are experiencing any hesitations or have further questions, contact our office. We are happy to ease your mind and get you on track to a beautiful smile. 513-232-8989

Continuing Education – Beyond the Basics Coding and Billing Conference

To better serve our patients, Dr. Michael Lee and the entire staff of the Cincinnati Center for Corrective Jaw Surgery are always looking for advanced education and training opportunities.

This November, Jen Carroll, our Financial Coordinator, attended Beyond the Basics Coding and Billing Conference at the Hyatt Coconut Point Resort in Bonita Springs, Florida. Sponsored by the AAOMS (American Association of Oral and Maxillofacial Surgeons), the hands-on conference provided Jen with the necessary tools to achieve coding compliance and attain optimal reimbursement while preventing fraud and abuse.

In addition to OMS-specific procedural coding, new content covered healthcare reform initiatives stemming from the Affordable Care Act, state insurance laws, reimbursement issues, audit tips, medical records documentation, managed care contracts tips, fraud and abuse, and more.

Further Reading: Arthroscopic Surgery using the McCain Technique – A New Option for Conservative Management of the Problematic TMJ

Further Reading: Arthroscopic Surgery using the McCain Technique – A New Option for Conservative Management of the Problematic TMJ

We are pleased to announce that the Cincinnati Center for Corrective jaw Surgery is now offering arthroscopic surgery to care for patients who present with jaw joint problems unresponsive to conservative management. Problems can include pain, limited opening, and internal TMJ conditions that range from clicking and locking of the joint to painful degenerative arthritis.

Size matters when it comes to successfully treating joint problems with arthroscopic surgery. The TMJ is not only small but it is surrounded by important anatomic structures that must be protected during the process of inserting the arthroscope and maneuvering it to fix the problem. Making arthroscopic surgery of the TMJ so challenging is the fact that the nerve that controls the movement of the facial muscles runs close to it in the tissue overlying it. Also, the middle ear sits just behind the joint so gaining entry to the joint without damaging the middle ear is tricky.
The TMJ is so small that it holds less than a teaspoonful of fluid. It is hard to believe that a joint so small with so little in it could cause so much pain and so much misery for so many people. Joint problems include clicking and popping in the joint with opening and closing of the mouth and pain from displacement of the joint disc. In other joints like the knee and shoulder these symptoms can be decreased by cleaning out inflammatory chemical particles in the joint and placing medications in the joint to lubricate it and decrease inflammation in the lining of the joint space. But unlike other joints, accomplishing this feat has been problematic because of potential complications with middle ear and surrounding nerves to the face and because of the relative size of the join to the size of the arthroscope going into it.

With the introduction of the McCain Arthroscope and the McCain Arthroscopic Surgical Technique, many of the complications with arthroscopic surgery of the TMJ have been greatly reduced.

This spring, I introduced the McCain Arthroscopic Technique and the McCain Arthroscope designed by Dr. Joseph McCain of the University of Miami. The arthroscope designed by Dr. McCain is unique for its size and ease of use. Dr. McCain is broadly recognized as one of the founding fathers of TMJ arthroscopy. I was trained by Dr. McCain in late winter of 2016 and during the spring of 2017 and I follow the McCain Technique for TMJ arthroscopic surgery.

The arthroscope Dr. McCain designed is special. He has been involved in the design since 1990 and the current scope is the result of a group of skilled engineers in Germany who designed the scope to Dr. McCain’s specifications. The scope has the most sophisticated optics available in small joint arthroscopy and provides excellent images given its micro size of 1.8 millimeters. Sixteen arthroscopes could be set side by side within an inch! See figure 1.

In figure 2, a healthy meniscus is seen overlying the condyle as it translates on the slope of the eminence to maximal opening. In figure 3, the hyperemic tissue of the posterior attachment is seen in a painful joint with anterior displacement of the meniscus upon opening.
The McCain Technique is minimally invasive. The procedure is quick and very effective with a success rate of 90%. More importantly it is safer than previously described arthroscopy techniques. The joint approach Dr. McCain teaches minimizes failed entry into the joint also minimizes complications associated with improper placement of the scope in the small upper joint compartment. Also, the small diameter of the scope allows for more mobility of the scope in the joint space which means more opportunity to break adhesions and clean inflammatory debris out the joint space.
According to the American Association of Oral and Maxillofacial Surgeons, 35 million people in this country suffer from varying degrees of TMJ dysfunction or TMD. Approximately 10% of this group will seek treatment for joint symptoms that do not respond to conservative therapy. The other 90% can be well managed with conservative therapy, therapy that can be initiated by and managed by the family dentist.

Our treatment algorithm begins with the dentist:
A. Prior to our consultation with the patient, we ask that the dentist fabricate an occlusal guard for the patient and initiate conservative treatment for any overlying muscle overloading or joint overloading as a result of clenching and bruxism.
B. If the dentist is comfortable with the management of the patient’s pain thru the use of anti-inflammatory medications, we request that these medications be added to the treatment regime if not contraindicated for medical reasons. Ibuprofen is to be avoided because of its anti-chondrocyte activity.
C. Amitriptyline or Clonazepam can be given by the dentist to decrease nocturnal bruxism. Clonazepam should be used only for one week as a trial. Patients who respond to it should be switched to Amitriptyline thereafter.
Most patients will be successfully managed at this point but those who continue to have pain need a referral to our office and further work up. These patients usually continue to suffer from:
1. Painful palpation of the lateral capsule of the TMJ.
2. Painful clicking, grating or popping of the joint
3. Painful opening or lateral movements of the lower jaw.

At the patient’s initial appointment I and my staff will evaluate them and obtain a history of their conservative treatment. Traditionally we will add or adjust medications and initiate aggressive physical therapy. To aid in our diagnosis, we will obtain a CBCT of the joints and, based upon our findings, consider an MRI scan following ADA protocols for imaging to determine meniscus status and position.

After further diagnostic imaging and targeted physical therapy we will see the patient back in our office and evaluate their progress. If less than sufficient from the patient’s perspective I will suggest minimally-invasive arthroscopic surgery if it is warranted from the findings of our imaging studies. A diagnostic arthroscopic procedure includes complete lavage of the superior joint space, a 7 point arthroscopic examination of the joint and installation of Na+ Hyaluronate along with a stem cell aspirant, platelet rich plasma or steroids. Successful treatment nears 90% in patients who have been properly worked up and well managed with conservative therapy.

To be sure, arthroscopic surgery of the TMJ is to be reserved for refractory cases of TMD. Proper vetting of the patient and strict adherence to accepted conservative management principles is key for success. While other conservative treatments such as two needle lysis and lavage of the TMJ are known to be successful, my preference for the McCain Arthroscope and Arthroscopic Technique is based upon the following reasons:

1. Minimally invasive entry into the joint with the McCain Technique
2. High success rate for superior joint puncture and navigation of the joint space owing to the small ( 1.8 mm) size of the arthroscope
3. Superior camera optics for the size of the scope allowing for accurate diagnosis of disc position and synovial tissue disease.
4. Second needle visualization in the joint to ensure complete irrigation of the joint space and removal of joint debris.
5. Easy second needle switch to second port for the introduction of instruments to debride the joint and release adhesions.
6. Direct visualization and the instillation of medicaments.

Please contact the Cincinnati Center for Corrective Joint Surgery for more information concerning arthroscopic surgery of the TMJ using the Dr. Joseph McCain approach to diagnostic arthroscopy.

Dental Implants for a New Holiday Smile

Dental Implants for a New Holiday Smile

It’s hard to believe, but the holiday season is right around the corner. This time of year brings many opportunities to spend time with friends and family, and gives you many opportunities to take great photos. If you tend to hide from the camera out of concern for the appearance of your smile, Dr. Michael Lee and the team at Cincinnati Center for Corrective Jaw Surgery can help. Dental implants are an ideal solution for missing teeth and will get your smile in picture-perfect shape in time for the holidays.

Dental Implants
For a long time, traditional dentures and bridgework were the only solutions for missing teeth. While these treatments still help many people, dental implants are quickly becoming the standard form of care. Implants are set apart as a superior treatment option because they:

• Offer a permanent tooth loss solution
• Are firmly anchored in the mouth and will not move
• Allow you to confidently bite and chew all kinds of food
• Are carefully colored to match neighboring teeth for a more natural appearance
• Special care beyond regular dental checkups and at-home hygiene is not required
• Special cleaners are not required

There are many reasons why people choose implants. Look forward to enjoying the holiday feasts and smiling confidently for holiday photos with this innovative approach to dental care.

Further reading: Dental Implants 101, and contact Dr. Michael Lee today to schedule a consultation.

Dr. Lee now provides a New Option for Conservative Surgical Management of the Problematic TMJ

Dr. Lee Now Provides a New Option for Conservative Management of the Problematic TMJ

We are pleased to announce that the Cincinnati Center for Corrective Jaw Surgery is now able to care for patients who suffer from jaw joint problems commonly known as TMJ or TMD with arthroscopic surgery.

What is TMJ & TMD?

TMJ stands for temporomandibular joint – the jaw joint. TMD stands for temporomandibular dysfunction. TMD relates to pain, limited opening, bite problems from muscle overloading and conditions that range from clicking, popping and locking of the jaws to rheumatoid arthritis. It’s hard to believe a joint so small with so little in it (the TMJ holds less than a teaspoonful of fluid) could cause so much pain and misery for so many people.

Arthroscopic Surgery
While arthroscopic surgery of large joints like the knee and shoulder is standard fare and widely available, arthroscopic surgery on smaller joints like the TMJ is less common. Like other joints, these symptoms described above can be decreased by cleaning out inflammation in the joint and placing medications in it – to lubricate it and decrease inflammation in the lining of the joint space. But unlike other joints, accomplishing this feat has been problematic for two reasons. 1) the potential complications with middle ear and surrounding nerves to the face and 2) the relative size of the joint to the size of the arthroscope going into it. Fortunately, these problems have been eliminated or greatly reduced with the introduction of the McCain technique and the McCain arthroscope.

The McCain technique and the McCain arthroscope
In the winter of 2016 and the spring of 2017, I was trained by Dr. Joseph McCain, broadly recognized as one of the founding fathers of TMJ arthroscopy, on the McCain technique using the McCain arthroscope. This spring, I introduced this special technique and tool to the Cincinnati Region.

Dr. McCain has been involved in the design of the arthroscope since 1990. It has the most sophisticated optics available in small joint arthroscopy and provides excellent images given its micro size of 1.8 millimeters, just over one 16th of an inch.

The McCain Technique is minimally invasive. The procedure is quick and very effective with a success rate of 90%. More importantly, it is safer than previously described arthroscopy techniques. Also, the small diameter of the scope allows for more instrumentation of the joint and more mobility of the scope in the joint space.

Our treatment algorithm

According to the American Association of Oral and Maxillofacial Surgeons, 35 million people in this country suffer from varying degrees of TMJ dysfunction or TMD. Approximately 10% of this group will seek treatment for their symptoms. The majority of those patients can be well managed with conservative therapy – therapy that can be initiated by, and managed by, family dentists.

Our treatment algorithm begins with the dentist:
A. Prior to our consultation with the patient, we ask that the dentist fabricate an occlusal guard for the patient and begin conservative treatment of the muscle or joint
B. If the dentist is comfortable managing the patient’s pain through the use of selective anti-inflammatory medications, we request that it be added to the regime, if possible.
C. Additional medications can be given to the patient to decrease grinding and clenching

Most patients will be effectively managed at this point, but those who continue to have pain usually suffer from:
1. The lateral capsule of the TMJ is painful to the touch (is this a correct rewording?)
2. Painful clicking, grating or popping of the joint
3. Painful and limited opening or lateral movements of the lower jaw

When a patient falls into the category above, we request that they be referred to our office for further evaluation and possible treatment. At their initial appointment, Dr. Lee and his staff will evaluate them and obtain a history of their conservative treatment and their response to it. Traditionally, we will add or adjust pharmaceuticals and initiate aggressive physical therapy. From a diagnostic standpoint, we will obtain a CBCT to evaluate the joints and, based upon our findings, consider an MRI to determine meniscus position and status.

After further diagnostic imaging and more aggressive conservative treatment, we will see the patient back in our office to discuss the most minimally-invasive therapy that can be employed – a diagnostic arthroscopic procedure. Successful treatment of cases that have been properly selected and well-managed with conservative therapy nears 90%.

Summary
To be sure, arthroscopic surgery of the TMJ is to be reserved for cases of TMD that are not resolved with conservative treatment. Proper vetting of the patient and strict adherence to accepted conservative management principles is key.

Please contact the Cincinnati Center for Corrective Joint Surgery for more information concerning arthroscopic surgery of the TMJ.

Four Ways Exparel, a Long-Lasting, Non-Opioid Pharmaceutical, Can Make Your Oral Surgery Recovery Easier

Four Ways Exparel, a Long-Lasting, Non-Opioid Pharmaceutical, Can Make Your Oral Surgery Recovery Easier

At the Cincinnati Center for Corrective Jaw Surgery, our focus is your recovery. That is why we are proud to offer Exparel (bupivacaine), a long-lasting, non-opioid pharmaceutical, at our practice.

Exparel could ease your recovery from your upcoming oral surgery, and in fact, if you’ve been putting off oral surgery such as getting your wisdom teeth removed, you might finally feel ready after learning about this new drug. While you are asleep, Exparel is injected throughout the surgery site and provides local anesthesia that can last 24 hours and sometimes up to two days.

Here are some of the ways Exparel help you through your postoperative period:

1. There’s no need to worry that pain will set in before the pain pills begin to work. When you first arrive home from oral surgery, there’s no need to time that first dose of pain medication just right, so you don’t experience pain before the Novocaine wears off. Plus, when you’re recovering, you may be tired and need plenty of rest. You will not need to set the alarm clock to take pain medication. There is no risk of losing track of when you took your last pain reliever and when it’s time for the next one. For an extended period of time following your procedure, Exparel will do its work, so that you don’t even need to think about pain medication.

2. It limits your chances of getting hooked on opioids. Opioids receive a lot of attention for their potentially addictive nature. This can even be a concern for someone taking Vicodin or Percocet for just a few days. And, opioids can cause other unpleasant side effects like nausea, vomiting and constipation; some people simply do not tolerate these medications well. Many people simply wish to avoid narcotics if possible. Exparel can reduce the number of narcotic pills you or your family member need to take.

3. You can stay more alert during your recovery. On narcotic drugs, patients often feel sleepy, dizzy, and unfocused – not the best for your son or daughter who needs to get back to studying for school. Following surgery, you may wish to take it easy, but your busy life may still get in the way and make that hard. You may have children depending on you or you may need to drive. Exparel minimizes your post-operative pain and may make your discomfort amenable to over the counter pain medications.

4. You can trust a drug that doctors have long used. Exparel contains bupivacaine, which doctors have relied on for pain relief at surgical sites since the 1950s. Exparel is formulated differently than bupivicaine to work slowly over a much longer period of time. So have peace of mind knowing that scientific innovation has updated an already well-established option. Exparel itself is well-tested and has been widely used since 2012.

No one enjoys recovering from surgery, but we want to help you make it as smooth and painless as possible. We would welcome the opportunity to talk with you about your individual situation and how Exparel, and our innovative Cool Comfort Wrap, can ease your pain in recovery. Call or email us for an appointment now.

Surgical Expertise | Technology-Driven | Dedicated to Patient Recovery

Case Study: Skeletal Deformities Involving the Maxillofacial Skeletal Complex

Skeletal Deformities Involving the Maxillofacial Skeletal Complex

This month’s case report demonstrates the team approach we use to treat more complicated skeletal deformities involving the maxillofacial skeletal complex.    These types of skeletal problems commonly include deformities of the nose and the bones surrounding the orbits.  They are still growth deformities however and should not be confused with congenital deformities of the maxillofacial complex such as Pierre-Robin Syndrome and Treacher Collins Syndrome.

Acquired skeletal deformities that are hypoplastic/hyperplastic in nature are commonly treated in private practice but the treatment of these acquired skeletal problems with orbital reconstruction and nasal reconstruction is not.  Very few orthognathic surgeons outside of academic settings can offer this valuable service to their patients.  A team approach is a must.  Having the right combination of a facial plastic surgeon and an oral and maxillofacial surgeon is not enough, however.  The magic ingredient?  A well trained operating room and anesthesia staff.

Performing nasal surgery and jaw surgery is a great benefit for the patient.  It saves the patient a separate surgery, anesthetic and hospital bill, not to mention the second period of recovery.  But doing them together requires a hospital-based anesthesiology department and operating room staff skilled at converting nasally intubated patients to orally intubated patients in the middle of a long, complex reconstructive surgical procedure involving the entire airway.

The case presented this month is commonly performed at Mercy Hospital- Anderson and is not possible without the skill and expertise of the operating room staff and anesthesiologists.

The patient in figure 1 is typical of individuals who present with skeletal deformities of the nose, midface and mandible.  From a frontal and lateral view, the sunken in look to the orbital bones and upper jaw are easily recognizable.  The nose appears large because it is long and narrow but also because it is projecting from a hypoplastic midface. The mandible appears narrow and prognathic, but in reality is not significantly enlarged, at least not horizontally. It is more so vertically.   The most common mistake made in cases such as these is for the surgical team to focus on the strong looking mandible and treatment plan the patient for an extensive mandibular setback procedure.  This is a disaster on many fronts – both aesthetically and more importantly from an airway standpoint.  Sleep-disordered breathing is certainly to follow!

There is always overwhelming dental compensation in these cases and the orthodontist must pay special attention to positioning the upper and lower incisors to obtain perfect incisor inclination before surgery.  Without proper placement of the incisors, overbite and overjet will be compromised and uncoupling of incisors can occur post-operatively.  Figure 2 shows the presurgical setup of a similar case where improper incisor set up limited overjet and overbite.

Compare this to the presurgical setup in our case, figure 3 and side by side models of the two cases, figure 4.

Fig. 3

Fig. 4

From figure 1, the hypoplastic look to the upper jaw, orbital bones and zygomatic arches is easily recognizable.  These areas will look even more sunken in if the maxilla alone is advanced.  Infraorbital rim/zygomatic bone augmentation is needed to obtain good aesthetics.  This graft is very simple to do once the infraorbital rim and the lateral aspect of the arch is dissected out of the overlying soft tissue and a pocket is developed next to the bone to accept the graft.  The graft is a combination of nonresorbable hydroxyapatite, collagen and water. They can be molded into soft wafers the size of miniature Hershey chocolate bars and placed under a heat lamp. (Figure 5)

After several hours of drying they can be slipped into place and positioned to obtain symmetry and projection of the infraorbital rim region.  (Figure 6)

Maxillary hypoplasia accentuates the complexity of any nasal deformity.  In our case, the nose appears elongated with a slightly downturned nasal tip.  It overwhelms the face.  Softening the dorsum of the nose and advancing the maxilla greatly improved the patient’s aesthetics. (Figure 7)

The patient’s mandibular prognathism, is accentuated by his midfacial hypoplasia. A common mistake made by the inexperienced surgeon is to focus on the prognathic mandible and aggressively set it back when, in reality, an extensive maxillary advancement is in order.  This can be facilitated by advancing the maxilla to its optimum aesthetic position using glabella vertical as a reference. (Figure 8)

Figure 9 compares the preoperative and postoperative facial result.  His preoperative and postoperative occlusion is seen in Figure 10.

Fig. 9

Fig. 10

This case demonstrates the nuances of combined orthognathic surgery and nasal reconstruction.  We thank Dr. David Quast for his referral of this most complicated case and for his orthodontic expertise in preparing him for surgery. Additionally, we thank Kevin Shumrick MD for his expertise in nasal reconstruction.

 Case Study: “C” Shaped Facial Asymmetries

Case Study: “C” Shaped Facial Asymmetries

Facial asymmetry is a relatively common maxillofacial skeletal deformity.  All patients have some degree of asymmetry, but minor discrepancies from one side to the other are not perceived by the average layperson and have no functional clinical significance.  Marked facial imbalances, however, can cause functional issues with mastication and overloading problems with the masticatory system.  While some skeletal asymmetries can be masked orthodontically, many cannot and, as interest in facial aesthetics increases, more patients are seeking orthognathic surgeons for treatment.  More orthodontists are referring patients for treatment of facial asymmetries as complaints of crooked smiles and deviated chins are voiced by their patients.  This is especially true among dental patients undergoing “smile aesthetics”.

Midface and mandibular skeletal asymmetries are complicated deformities involving all three planes of space and encompass yaw, pitch, and roll of the jaw bones.  Understanding the movement of the jaws in three planes of space is very important because success is dependent upon removing all bony interferences at the time of surgery to ensure a stable outcome. 

Cone beam CT scanning along with three-dimensional virtual surgical planning has been a game-changer in this regard.  Through these advanced technologies, orthognathic surgeons have the ability to see the midfacial and mandibular skeletal deformity clearly and from all angles.  Figure 1 shows a patient preoperatively and the extent of the skeletal facial asymmetry. 

Facial asymmetries can be categorized into four distinct groups with the simplest asymmetry being confined to the body of one side of the mandible and the most complicated asymmetries being what is termed a “C” shaped asymmetrical skeletal pattern because it involves both the upper and lower jaw.  With this type of deformity, as demonstrated in Figure 2, the condyle, mandibular body and symphysis of the mandible is affected in combination with maxillary canting and yaw. 

The patient in Figure 1 is a 22-year-old male with a facial asymmetry involving both the maxilla and mandible in a classic “C” shaped pattern.  There is a definite cant to both the midface and mandible with a severe deviation of the lower jaw to the left and a corresponding shift of the mandibular midline to the left side.  Canting of the maxilla follows the cant of the mandible with a midline shift to the left as well.

Virtual surgical treatment planning allows for a three-dimensional view of both the maxilla and mandible to better evaluate yaw of both jaws.  Evaluating and correcting this yaw has plagued orthognathic surgeons until virtual surgical treatment planning became available five years ago.  Figure 3 demonstrates the pre-surgical and post-surgical rotation of the jaws and correction of the yaw. 

In Figure 4, it is easy to see the extent of the maxillary cant after the mandible has been corrected for cant and deviation. 

Note the sagittal advancement on the left side of the mandible (Figure 5), compared to the right side that actually went backward as the asymmetry to the left was corrected and the midline of the mandible was placed on the midline of the upper jaw. 

Leveling the maxilla requires raising it on the right side almost 2mm and lowering it on the left by just as much (Figure 6).  

Advancement of the maxilla by 6mm corrected the anterior posterior position of the midface and corrected the Class III pseudoprognathism (Figure 7). 

Figures 8 and 9 compare the pre-operative and post-operative result.  Good aesthetics is accomplished along with re-establishment of normal function.  The chin is still asymmetrical as was noted in the virtual surgical planning.  A genioplasty procedure was declined by the patient.

 “C” shaped facial asymmetries are the most difficult to diagnose and treat.  Postoperatively they require close follow-up by both the orthodontist and the oral surgeon because shifting can occur from muscle function and the complexity of the skeletal move.  Three-dimensional virtual surgical planning has lessened relapse dramatically by exposing bony interferences that prevent passive movements of the mandibular segments.  This can be seen in a close-up of the left sagittal split osteotomy site.  Virtual surgical treatment planning identifies these interferences so they can be removed at the time of surgery.  (Figure 10)

I thank orthodontist, Jay Parekh, DDS, for referring this most-complicated case and having confidence in our ability to diagnose and treat complex deformities of the midface and mandible.