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Orthognathic surgery in conjunction with orthodontics and other dental disciplines is a confusing and sometimes frightening concept for many patients. For those people who need surgical correction the alternatives are few. These patients need to be educated in terms that they can understand but yet do not fail to give them detailed insight into what they will be facing. Presented here is Dr. Sarver's handout for patients (and their families) contemplating orthognathic surgery. This is COPYRIGHTED material and is not meant for use in your office, but is presented as a model to emulate. Use this example as a guide for constructing your own information handout. The Orthodontic CYBERjournal thanks Dr. Sarver for sharing work that obviously has taken a great deal of time and effort to put together.

Orthognathic surgery is an unfamiliar term to most people. This booklet is designed to give you better understanding about the purpose, procedures, and results of orthognathic surgery. It is our goal for you to feel completely informed and comfortable with your treatment, so we have designed this booklet to take you step by step, from start to finish.

The purpose of orthognathic surgery is to correct functional and esthetic problems that are due to underlying skeletal deformities. Orthognathic surgery is often the treatment solution in cases where the bite problem is so severe that braces alone aren't enough to correct the problem, or where orthodontics alone would compromise your facial appearance. Surgery may be avoided in some adolescents through growth modification and braces, correcting the growth pattern during the remaining growth period. These treatment options are limited in adult patients.

Severe malocclusion {bad bite} may cause many functional problems. You may have already experienced some of the following: inability to chew food properly which compromises digestion; speech problems; facial muscle dysfunction characterized by headaches, joint pain, etc.; and periodontal trauma.

Orthognathic surgery provides us with the opportunity to improve both functional and cosmetic problems at the same time. Most are not very familiar with the procedure and therefore are uncomfortable, even fearful, in considering it as a treatment option. Again, the information in this booklet is designed to take you step by step through the process involved with orthognathic surgery so you can fully understand the entire orthodontic and surgical experience.

We will be happy to help you with insurance processing and will discuss flexible financial arrangements for uncovered procedures. Also, a copy of your radiographs will be provided for the oral and maxillofacial surgeon to submit to your insurance company for preauthorization of available benefits. This determines the extent of your insurance coverage for the recommended procedures. Some patients prefer to wait for insurance approval before initiating treatment; however, this is not always necessary. Medical insurance, not dental, is generally responsible for coverage in orthognathic surgery. In the majority of cases, your insurance carrier should cover hospitalization, anesthesia and surgical fees, but may not cover the orthodontics required for successful treatment.

We will be glad to assist you in filing your insurance, but we cannot guarantee it will cover your orthodontic care. What's the biggest problem at present with surgical-orthodontic treatment? It's financial, not related at all to the treatment itself. Until recently, medical insurance typically covered the surgery and the associated hospitalization. Under standard medical insurance plans it still does, which is reasonable enough, given that the underlying problem is a jaw deformity, not unlike a congenital deformity of any other part of the body. But with benefit reductions and HMO contracts, in many areas jaw surgery now is denied, admittedly as a cost-reducing measure. As a result, most surgeons offer outpatient services and payment plans in an effort to make these procedures affordable even without insurance coverage. You will need to consult with the surgeon's office as to how you and your insurance company can communicate your needs clearly.

The level of sophistication in dentistry, orthodontics, and oral and maxillary surgery has increased dramatically in the past decade. This is partially because of improved techniques and technology, but is due primarily to the increased cross-fertilization of knowledge between specialties and communication between these groups.

To achieve maximum results, collaboration and cooperation between Dr. Sarver, your dentist, oral and maxillofacial surgeon, and plastic surgeon can be facilitated through graphic imaging and interdisciplinary planning. Dr. Sarver and colleagues have pioneered this approach to treatment here in Birmingham. Dr. Sarver's book, Esthetic Orthodontics and Orthognathic Surgery, is used by the various medical and dental disciplines in teaching as well as clinical practice.

This approach is more than "just teeth," it is a comprehensive approach to treatment to capture the result desired by the patient. The use of digital imaging and computers provides excellent interaction with you, the patient, to design just the right type and amount of treatment each patient might desire.

The case pictured below is an excellent example of this teamwork concept. This patient underwent orthodontic treatment, and when ready for her surgery, her surgical plan was determined with her input via computerized graphic imaging. This was followed by a procedure to advance the lower jaw and chin, with a simultaneous rhinoplasty to improve her midface. When her braces were removed, her dentist bleached her teeth to achieve the most ideal and natural shade, and then porcelain veneers were added and cosmetic restoration of some missing teeth was performed to provide just the right finish to her smile.

PRESURGERY/ SURGERY

The following is a general sequence of events that occurs once your treatment begins. Please remember that each treatment plan and case may vary from this general sequence of events.

PRESURGICAL ORTHODONTICS ORTHODONTIC APPLIANCES {Braces}

In order to prepare your teeth for your orthognathic procedure, we will place braces on your teeth to begin their alignment. The purpose of the presurgical phase of orthodontics is generally to:

ALIGN CROWDED TEETH
DECOMPENSATE INCISORS {ALIGN THEM PROPERLY WITHIN THE JAWBONE}
COORDINATE THE TEETH SO THEY WILL FIT WHEN THE SURGERY IS PERFORMED

Presurgical orthodontics may take as few as 6 months or as many as 18 months, depending on your needs. During your treatment, impressions will be taken in order to check the progress of the orthodontic alignment. These impressions are referred to as surgical check models. Once we feel your presurgical goals have been accomplished and have placed an archwire heavy enough for surgery, we will then make an appointment for your surgical work-up.

THE SURGICAL WORK-UP When the presurgical phase of orthodontics is complete, radiographs, photos and models will once again be gathered at this important appointment. We will also contact your surgeon's office to find out approximate dates available and to initiate final insurance approval, if it is required. Our final surgical plans will be determined from the work-up records. Dr. Sarver and your surgeon will consult to decide on the recommendations they will make to you to achieve the best results. Superimposition of your profile video image and X-rays will serve as a valuable guide for achieving your desired esthetic goals. From the surgical check models, a plastic splint, called the occlusal wafer, will be fabricated for the surgeon as a guide for the desired tooth relationship.

ORTHODONTIC APPLIANCES

The purpose of the presurgical phase of orthodontics is to align the teeth so the bite is correct when the surgery is complete. At the time of surgery, we will place surgical pins which are threaded through a special slot in your orthodontic brackets. These serve as an attachment during the surgery for the surgeon to be able to secure the teeth. The braces are not removed before your surgery.

SEQUENCE OF TREATMENT EVENTS

Diagnostic records and analysis
Insurance predetermination and treatment plan confirmation
- Consultation with oral and maxillofacial surgeon
- Consultation with dentist, other specialists if needed Placement of orthodontic appliances (braces)
Presurgical phase of orthodontics
Presurgical work-up and analysis
Appointment with surgeon(s) to select surgical date
Surgery and postoperative rehabilitation Finishing orthodontics
Removal of braces, placement of retainers
Final dental equilibration, restoration, and cosmetic finishing

Generally, you will be admitted to the hospital the morning of your scheduled surgery. The length of your surgery depends on the procedure being performed. The length of your hospital stay also varies according to your procedure. Some procedures may be done on a 23-hour outpatient basis. Your surgeon should discuss with you all these necessary details prior to your surgery.

There are many side effects to general anesthesia that you may possibly experience after surgery. These include some weakness, dizziness, and nausea. Drugs are generally administered during and after your surgery to prevent nausea. We must emphasize that this side effect is very rare, and is generally controlled with medicine. We would also like to point out that after general anesthesia is administered, there may be a feeling of depression several weeks later. Please be aware that this may happen and do not be alarmed. Make sure your family is aware of this as well.

Your anesthesia will be administered through nasal intubation. In other words, a tube is passed through your nose to the lungs to administer the anesthetic agent. A tube is also passed to the stomach in order to keep the stomach empty before, during, and after surgery to help control nausea. You should expect to have a sore throat for 1-2 days following your procedure due to the intubation.

Incisions are made on the inside of your mouth for access during the surgical procedure. As a result, there is no external scarring. These incisions are typically located in the folds of tissue and are not usually visible after your surgery. The sutures used on the incisions either dissolve or are removed after 5-7 days.

Intravenous fluids are administered at the time of surgery. The I.V. is used during surgery to maintain adequate fluid levels and is used after surgery to administer pain medication, antibiotics, etc. It is generally removed the day after surgery.

Immediately following surgery your diet is limited to soft foods. With a creative imagination, you will not be as limited as you might think. Your surgeon's office should provide you with more guidance on such a diet. Examples of soft foods:

Because the muscles in your mouth are not very strong immediately after the surgery, and your new bite feels different, it may be more difficult to chew. Foods such as breads and most meats will be difficult to eat. About 4 weeks after surgery, however, your surgeon will recommend trying more normal foods.

As far as your appearance is concerned, any bruising that may occur will be gone after a few days. Swelling, however, takes longer to dissipate, but most will be gone after approximately 2 weeks. You will be much more conscious of your appearance than will the people around you. Although your family and close friends will notice a change and their reactions may vary, remember that the swelling will decrease every day, and after 2 weeks the majority of swelling should be completely gone.

You should expect some soreness in lengthy conversations; however, the more you talk, the more you exercise your weakened muscles and aid your recovery. You may be sore but try not to depend on writing notes to communicate. Go ahead and say it!

This depends on the complexity of the procedure and type of problem you have. Studies show that people grow very impatient with the braces at 6 months postoperatively and can become depressed if the braces are not off by then. You can insure that your braces come off as soon as they can by keeping appointments and wearing elastics as prescribed.

With the use of elastics and different archwires, we will complete final bite detailing. There is often some space closure and final root positioning left to be done the last few months as well. Cooperation from the patient during this time will play a large part in the completion of treatment. Please remember we want your results to be as excellent as possible. So please be patient; we want to do a good job!

DR. DAVID SARVER, graduated from the University of Alabama School of Dentistry in 1977, and was named by ODK as the Outstanding Professional Student in the Medical Center. He completed his certification in orthodontics at the University of North Carolina, where he also obtained his postdoctoral master's degree in 1979. He then opened his practice in Birmingham in 1979. Dr. Sarver is a Diplomate of the American Board of Orthodontics, a member of the Angle Society of Orthodontists, and currently serves as an adjunct professor at the University of North Carolina. He has authored the orthodontic text Esthetic Orthodontics and Orthognathic Surgery, which is used in clinical and university teaching. He and his wife,Valerie, have three children-Dave, Leigh and Suzanne.

THE INITIAL RECORDS During your first visit, a set of diagnostic records will be taken to determine the nature of your problem and what can be done to correct that problem. After processing and analyzing these records, we will meet with you for a consultation appointment to discuss your treatment options. The following explains the individual records that may be taken and their purpose. CEPHALOMETRIC {LATERAL SKULL} RADIOGRAPH This side view radiograph of the face allows us to compare your tooth and jaw relationships to normal or ideal measurements. Computerized analysis permits prediction of planned bony movements and resulting soft tissue response through the merger of the facial pictures with the cephalometric radiograph. This permits us to show you the facial changes which you might expect with treatment. PANORAMIC RADIOGRAPH The panoramic radiograph is a composite radiograph of the teeth as well as both jaws. In one film, it shows us if you have the normal number of teeth, wisdom teeth, missing teeth, impacted teeth or extra teeth. TEMPOROMANDIBULAR JOINT TOMOGRAPHY These jaw joint tomograms are often required to help us determine any abnormalities in the shape and condition of the condylar {hinge} portion of the lower jaw, as well as to analyze the range of motion that occurs upon opening the mouth. There are a number of local and systemic disease processes which can affect the temporomandibular joint, and in many cases this film can help identify problems you may not even be aware of. STUDY MODELS Dental models will be used to study the dental problems as they exist at the beginning of treatment and are used for reference during pre-treatment planning. In many cases, the models are placed on an articulator, a device which closely simulates jaw movement. PHOTOGRAPHS Frontal and side facial photographs are a part of the overall work-up of the case. These facial pictures serve as visual aids for bony and soft tissue analysis so that the facial aspects of treatment can be thoroughly evaluated. Photographs of the teeth will also be taken to provide an accurate record of the mouth at the time treatment begins.
	One of the most rewarding aspects of orthognathic surgery is improved self-esteem.

	Cephalometric Radiograph	Computerized Analysis

	Panoramic Radiograph

	Tomograms are special X-rays to specifically examine the temperomandibular joint.

COMPUTERIZED DIGITAL IMAGING At the time of your consultation visit, we will utilize digital imaging in the discussion and planning of esthetic changes. In this process, a digital picture is modified to illustrate approximate profile changes which may occur in your proposed treatment plan. Also, other options of treatment may be illustrated at this time. This is an excellent way for you, Dr. Sarver and your surgeon to discuss and understand mutual treatment goals. Imaging will be used, again in the evolution of the final treatment plan, and will be discussed further in this booklet. CONSULTATION APPOINTMENT While surgery may be the best option to achieve desirable functional and cosmetic results, it is an elective procedure, a may be a treatment option you do not choose. Other treatment options will be presented to you in the consultation appointment. In this visit, we will discuss: THE OVERALL ANALYSIS AND PROBLEM LIST TREATMENT OBJECTIVES WHY YOU ARE HERE AND CONSIDERING TREATMENT THE ANTICIPATED TREATMENT SEQUENCE o OPTIONAL TREATMENT PLANS, THEIR STRENGTHS AND WEAKNESSES RELATIVE TO YOUR OVERALL TREATMENT OBJECTIVES Because treatment in adults often involves more complex problems, referrals to other specialists {periodontists, endodontists, etc.} may be necessary. Also, if we find that tooth removal is required for orthodontic purposes, a referral will be sent to your dentist or oral surgeon at that time. WHEN DO YOU DO SURGICAL-ORTHODONTIC TREATMENT? Prior to adolescence, surgery is almost exclusively for children who have congenital deformities or problems related to trauma. For children with severe growth distortions, guiding growth is better than surgery, if it's possible. So surgical-orthodontics rarely is indicated before the adolescent growth spurt ends. That doesn't mean surgery has to wait until all growth has ended. Jaw surgery has surprisingly little effect on growth. So if the problem is deficient growth of the mandible {Class II} or maxilla {Class III}, it's okay to advance the deficient jaw soon after the growth spurt ends, as soon as you can tell what its final position should be, and possibilities for effective growth modification have disappeared. When deficient growth is the problem, it isn't necessary to wait until age 18 or 20 for jaw surgery.	BEFORE	PREDICTION

	Computerized Digital Imaging allows the patient to see the projected changes anticipated with the proposed treatment plan.
	AFTER

	BEFORE

	AFTER

BEFORE	AFTER	.................	BEFORE	AFTER

ADVANCEMENT OF THE LOWER JAW			REDUCTION OF THE LOWER JAW

BEFORE	AFTER		BEFORE	AFTER

		BEFORE	AFTER
OPEN BITE	BEFORE
OPEN BITE	AFTER

TREATMENT OF LONG-FACE AND GUMMY SMILE	BEFORE	AFTER	BEFORE	AFTER
TREATMENT OF LONG-FACE AND GUMMY SMILE
TREATMENT OF SHORT-FACE	BEFORE	AFTER	BEFORE	AFTER
TREATMENT OF SHORT-FACE

RHINOPLASTY	BEFORE	AFTER	BEFORE	AFTER
RHINOPLASTY
	COMPUTERIZED PREDICTION	TREATMENT GOAL	BEFORE COSMETIC DENTISTRY	AFTER COSMETIC DENTISTRY

APPLIANCE REMOVAL AND RETAINERS This is the day you have waited for-the day your braces are removed! Most often, a fixed retainer will be bonded to the inside of the lower front teeth before removing the braces. The upper retainer is usually removable. One week after removing your braces, you will receive this retainer and instructions on care and use. FINAL RECORDS Once your treatment is complete, a set of final records will be taken. These records consist of the same records taken at the time of your initial visit. This appointment is generally 1-2 weeks after your braces are removed. RETENTION & RECALL VISITS Further appointments with Dr. Sarver are necessary after your braces have been removed. These periodic visits will be every 3-6 months and are necessary to adjust your retainer and check your bite. Because of the special nature of orthognathic treatment, Dr. Sarver prefers to follow his surgical patients for many years after treatment. Retention is the crucial part of your orthodontic treatment. Retainers are to be worn at all times during the first few months to one year following treatment. Once you have reached a point where your teeth and bones have stabilized, you will be able to limit the wearing of your retainer to only while sleeping. Keep in mind, however, that the more the retainers are worn, the less chance there is of anything moving out of place. EQUILIBRATION AND FINAL RESTORATIVE DENTISTRY In some cases, "equilibration" may be needed. Equilibration is simply the "fine-tuning" of your bite and is done by your dentist. Any bridges, replacement crowns, etc. should also be done at this time. COORDINATION WITH YOUR DENTIST Many patients requiring orthodontic/surgical treatment of their malocclusion also require sophisticated dental care to be closely coordinated with the treatment. Your dentist will be consulted and called upon to help shape the goals of your treatment, and in many cases provide treatment from major dental reconstruction to the "finishing touches" that make a big difference in both your functional and esthetic outcomes.	BEFORE	AFTER

	BEFORE	AFTER

	BEFORE	AFTER

	BEFORE	AFTER	BEFORE	AFTER
HORIZONTAL MAXILLARY PROTRUSION (OVERBITE)
	BEFORE	AFTER	BEFORE	AFTER
HORIZONTAL MAXILLARY DEFICIENCY (UNDERBITE)