An increasing number of patients complain about unsatisfactory outcomes of orthognathic surgery, desiring reoperation or revision surgery to improve jaw function and facial aesthetics. After reoperation or revision surgery, most patients showed a full Class I occlusion of the jaw or a normal relationship between teeth, jaw and jaw. Full Class I occlusion is the occlusion and balanced profile in the anteroposterior plane that patients want as a functional and aesthetic result of Orthognathic revision surgery. Major complications seldom occur in Orthognathic revision surgery. According to a recent clinicians’ evaluation, a postoperative evident functional improvement was achieved in 92.9% of patients, 91.4% were satisfied with the aesthetic outcomes achieved, also.
Corrective Jaw Surgery refers to a range of orthognathic surgical procedures
Including most common jaw surgeries such as lower jaw surgery, double jaw surgery, bite correction. Revision corrective jaw surgery is any type of orthognathic surgery that is used to correct a previous surgical procedure.
The goal of reconstructive jaw surgery is to improve both form and function in the case of congenital concerns or irregularities that are the result of trauma or disease.
What is corrective jaw surgery?
Reconstructive jaw surgery corrects issues related to the jaw working improperly, the appearance of the jaw or both. Some people may require reconstructive jaw surgery after birth due to a congenital birth defect. The need for corrective jaw surgery may also be caused by facial trauma or disease.
For younger patients, the need for corrective jaw surgery may become apparent after their physical development has shown that their jaws are misaligned, or are growing at different rates. This typically happens during or following adolescence. Reconstructive jaw surgery may be used as a last resort following orthodontic correction, which often can correct dental problems but not more serious jaw
Reasons for Revision Orthognathic Surgery
Wrong diagnosis
Receiving different surgery although patient needed double jaw surgery
Patient needed double jaw surgery because of protruding chin or facial asymmetry but received facial contouring surgery without satisfying results
Patient has a protruding chin or microgenia but received a mouth protrusion correction surgery without satisfying results
Patient was diagnosed wrong or was afraid and received other surgery but not satisfied with the results
Wrong operation
Side effects and unsatisfactory results even after two-jaw surgery
Appearance and jaw function still has a problem after two-jaw surgery
Pushed the lower jaw too far which made the sides of the nose and mouth collapse
Nerve damage, muscle damage or other side effects have been caused during the surgery
Reasons why revision orthognathic surgery is difficult!
Incised Jaw Bones
Jaw bones have been already incised. It is difficult to make another incision for shape and symmetry.
Lack of Pinning Sites
After existing pins from past two-jaw surgery are removed, there is not much space for new fixing pins.
Twisted Anatomical Structure
Facial anatomy including the bones, nerves, muscles, and skin tissues are already transformed.
3 Key Points for Orthognathic Surgery Reconstruction
Precise Simulation
Jaw bone has been incised and structure has been transformed. It is important to precisely comprehend remaining bone and nerve structure, and run a precise simulation.
Find pinning sites & Reliable pinning technology
Bones were already pinned before. It is important to find right pinning sites to stop the bones returning to their previous sites.
Rich surgical experience
Double-jaw surgery reoperation is reconstruction of already transformed anatomical structure. Therefore, the surgeon should have anatomical knowledge and experience.
Most surgeons do not like to re-do another surgeon’s work. We have the best chance of getting the best results the first time. If the first surgery did not achieve the treatment objective, repeat surgeries are a lot more difficult. After the first surgery, the original anatomy would have been changed and there would be scarring. The usual tissue planes that we work on will no longer be there and anatomical structures such as nerves and blood vessels may not be reliably located based on the usual landmarks that we use. But these are not the most difficult challenges that repeat surgeries present. The most challenging part is the psyche of a patient who has undergone a surgery and the accompanying morbidity. Nonetheless, we can’t cherry pick our patients.
Correcting residual physical deformity
As it turned out, it was a very nice patient. He understood perfectly each of the surgeries that he had undergone and never had one bad word about the previous surgeons. He was not going after unrealistic aesthetic enhancement but just wanted achieve better function. The first surgery developed some complications that led to a wrong biting position and the subsequent surgeries could not correct it but added more collateral damage. He had a genuine physical problem that needed to be treated. However, the jaw had already had multiple surgeries and with each surgery, the blood supply to the bone diminished a bit more. My main concern is that the bone may not heal if surgery is done again. We tried other treatment such as pain management with a pain specialist, jaw repositioning splints with a prosthodontist, etc. After several months, and quite few flights in and out of Singapore, he decided that he still want to have surgery. I did another round of orthognathic surgery for her but as expected, healing was compromised and delayed and we spend quite a bit of time managing the complications. Some of my colleagues thought that I was crazy to do the surgery but I felt that she has a physical problem that needed surgery and I was happy to help. Despite a difficult recovery, he was a grateful patient who still sends me Christmas cards.
Re-doing to enhance aesthetics
Not all my re-do patients are happy. I have had a patient (another medical tourist), who had undergone corrective jaw surgery many years ago. She was not happy with the results and after ten years decided to have a second surgery. Unlike the earlier patient, she did not have an obvious physical deformity. However, she was very clear about what she wants and she can describe to me in vivid detail what she did not like and what she wanted to change. We did a few rounds of consult to discuss the surgery and she finally decided to proceed with the surgery. As there was only one round of surgery done and it was ten years ago, the tissues were not significantly altered. There was only minor challenges during the surgery from the scarring and fixation plates used in the previous surgery but everything went well. There was no complication in the healing process and the patient was happy with what she saw in the mirror. However, a few weeks later, she changed her mind and requested for some minor changes to the position of the jaw. I explained that another round of surgery was not good for her. The patient was unhappy and I was feeling miserable, regretting my decision to do the surgery.
Moral of the story
Revising or resurgery to “fix” previous corrective jaw surgery is tricky. It is technically more difficult due to the scarring of tissues, altered anatomy, compromised blood supply, buried fixation plates and screws from previous surgeries. However, beyond the technical difficulties, the patient’s mentality plays an even more important role. If there is a readily perceptible deformity, re-doing the surgery will usually benefit the patient. However, in situations where the patient does not have a manifestly obvious physical deformity and the objective is to changed one normal appearance to another normal but more preferred appearance, the benefit of a repeat orthognathic surgery may be questionable.
