Dentofacial Anomalies

Dentofacial deformities are common in the general population, ranging from mild abnormalities of the malocclusion to extensive and widespread deformities involving the entire face and skull. Perhaps no other area in facial plastic surgery yields as gratifying and as outstanding aesthetic and functional results than the treatment of dentofacial deformities. The orthognatic surgical treatment of deformities of the teeth and jaws requires a multidisciplinary team approach.  Although many deformities of the teeth can be corrected by orthodontic treatment alone, more extensive deformities require a surgical approach to treating dentofacial deformities requires special expertise in the care of jaw problems, as well as in the treatment of soft tissue deformities of the face. Typically, both the soft and hard tissues of the face, along with the teeth and bite, need to be considered in formulating a definitive treatment plan, which will lead to the best facial balance outcome.

Need more information?

 If you would like to learn more about having an Orthognatic Surgery that will suit you best, we invite you to meet with Dr.Srikanth Yadav Puligilla for a private consultation at our office.
Please contact us to schedule an initial consultation with Dr.Srikanth Yadav Puligilla to make an appointment. You may also fill out our contact form to make an appointment.

What is Orthognatic Surgery?

Orthognathic surgery is an unfamiliar term to most people.  Orthognathic surgery is to correct conditions of the  jaw  and  face  related to structure with  malocculation problems owing to skeletal disharmonies, or other  orthodontic  problems that cannot be easily treated with braces.

What may be achieved with Orthognatic Surgery?

Some people are born with poorly aligned jaws. Others develop problems as the bones grow or as a result of an injury. Orthognathic surgery realigns facial bones, making the jaws work together better. Surgery is only one part of the treatment process. In most cases, treatment to move and straighten the teeth (orthodontics) is needed before and after surgery. This combination of treatments can relieve the problems caused by teeth and jaws that are out of alignment. The goals of treatment are the intended consequences of treatment. The goals include functional occlusion, facial balance, stability of changes, TMJ health, airway enlargement, and patient satisfaction. The method of treatment is designed to achieve these goals while avoiding complications. The objective of orthognathic surgery is to achieve balance in the face and occlusal stability bite. Various techniques will be adapted to your special circumstances to achieve your best possible result.

Who is a candidate for Orthognatic Surgery?

All patient after being evaluated by an orthodontic specialist and can not be easily treated by braces and with facial disharmony are candidates. These anomalies are long face with gummy smile, upper jaw deficiency, short face deformity, open bite, upper and lower jaw asymmetry, cleft lip and palate, craniofacial deformities and trauma, maxillofacial deformities and trauma, lower jaw protrusion, lower jaw recession, chin deformities, sleep apnea and lower jaw fracture consolidation anomalies.

What types of dentofacial imbalances exists?

Not all, but most dentofacial imbalances will fall into one of the following categories:

• Retrognathism: This imbalance is often referred to as an overbite wherein the lower jaw appears retruded or shortened.

• Prognathism: This is the opposite situation in which the lower jaw appears more prominent or longer and is often referred to as an underbite.

• Apertognathism: This condition is defined as an open bite, where the front teeth do not meet. It is often combined with either condition 1 or 2 above.

• Asymmetry: This situation occurs when the jawbones appear tilted or rotated such that the face appears larger (or more prominent) on one side versus the other. It can occur in combination with any of the above categories.

• Vertical Excess and Deficiency: Relationships of the jaws and face appear long or short in a vertical direction. This also will occur in combination with any of the above situations.

What should I expect from my consultation?

During your consultation, you will learn about the Orthognathic Surgery treatment plan and discuss your needs and concerns. Seeing a patient with extensive deformities of the face, jaws, and teeth requires a systematic evaluation. Dr. Srikanth Yadav Puligilla will carefully examine your proportion of your entire face the orbital region, as well as the nose, lips, and mouth, which must all be evaluated. In addition, functional problems with the bite problems with dental hygiene such as the recession of gums, abnormalities of the teeth, and functional compromise of the airway, such as sleep apnea. The face is analyzed clinically and cephlometrically. In the profile view, the clinical and cephalometric examinations analyze the face anteroposteriorly. The frontal clinical view is responsible for revealing midlines, cants, yaw, and outline of the face. After that, he will determine what type of treatment you need to best maximize your result. Computerized facial imaging may be recommended to assess the potential treatment modalities and their relative benefits. Together with the orthodontist specialist, a formal treatment plan is established. The orthodontist specialist will lead teeth to its normal position, and Dr. Srikanth Yadav Puligilla will lead the skeleton and face to the balanced position of a beautiful face. After your consultation, we will take photographs for your medical record and we will discuss the surgery fees and scheduling dates. You should come to the consultation prepared to discuss your medical history. Also provide information about any medical conditions, drug allergies, medical treatments you have received, previous surgeries, and medications that you currently take. It is important for you to provide complete information.

Dr. Srikanth Yadav Puligilla will focus on:

 • Medical history:  Standard but pertinent questions are asked which impact the dental treatment.

 • Patient motivation: Questions are asked of the patient to reveal their motivation for treatment. Treatment should be devised which addresses the patient’s actual desires relative to outcome. Understanding the patient’s actual dental, facial and symptom expectations can alter treatment. It is better to have this information before treatment than for an unhappy patient to inform the treating doctor that the result was not what the patient sought.

 • Facial examination: The bite examination reveals that bite correction is necessary while the face indicates how to correct the bite. Bite correction can be accomplished by several methods all of which affect facial balance differently.

An organized frontal and profile clinical facial examination must be done prior to selecting the occlusal correction strategy. Additional facial input is revealed by some cephalometric examinations.

 • Model examination: Model analysis reveals information required for correct treatment. Mounted models are the most accurate means of revealing overbite, overjet, midlines, and posterior occlusal relationships. Handheld models are not used frequently but are very important especially in cases of class II or class III malocclusion. The handheld models can be placed in a class I occlusion which reveals arch width/form and curve of Spee discrepancy. This information is particularly important in revealing if arch form/width and curve of Spee can be successfully treated without surgical assistance.

 • TMJ history/examination: Dividing the TMJ history into the pathologic groups of the disc, muscle, and joint instability helps to reveal existing disease states. The thorough examination consists of organized clinical and imaging protocols. Greatly important to treatment stability is the morphologic stability of the TMJ’s (tomograms/head film showing resorption). Without a stable foundation (TMJ’s) bite and facial correction are doomed to failure as joint changes lead to mandibular relapse.

 • Airway examination: Three airway variables are evaluated when making treatment decisions: the existing airway, the patient’s age, and the patients anticipated weight gain with aging. A small airway gets smaller with age and weight gain. The question must be answered, how the treatment will affect the 3 airway variables. Bimaxillary advancement opens the airway while any jaw setbacks diminish the airway. Treating the occlusion orthodontically because the occlusion can be corrected orthodontically may be ill-advised in the presence of a small airway.

 • Cephalometric examination: Cephalometric examination should reveal dental, skeletal, and facial problems. By revealing these problems a thorough treatment plan can be devised.

 • Model surgery: Model surgery is done on a semi-adjustable articulator and is determined by facial needs. Anteroposterior model movements are determined by the facial requirements as exposed by the profile clinical facial examination and cephalometric examinations. Model movements involving midlines, cants, and symmetry are determined from the frontal clinical facial examination.

Process for Correcting Dento-Facial Imbalances

It is important to recognize that a dentofacial imbalance is a condition of bone development and consequently a misalignment beyond the teeth alone. When only the teeth are in an improper position, then orthodontics alone will be adequate to correct any existing problems. However, in the presence of a skeletal (bone) discrepancy or disharmony, the jawbones will need to be surgically repositioned as well to get a better face profile and alignment.

A surgical plan can then be mapped out to pre-determine all phases of the surgery. Correction of all imbalances can almost always be achieved by combining specific bony cuts and movements, including such procedures as:

 • Lefort I Osteotomy of the Maxilla: An osteotomy is defined as a cut in the bone. A Lefort I osteotomy is a bony cut through the maxilla at a level just below the nose, extending around the entire aspect of the upper jaw.

 • Osteotomy of the Mandibular Ramus: A sagittal split osteotomy which allows the lower jaw to be slid forwards or backward or a vertical osteotomy which allows the lower jaw to be pushed backward.

 • Genioplasty: A bony cut through the chin allowing for its movement in any desired direction.

A combination of the above procedures, with modifications, will solve most dentofacial deformities and lead to a vastly improved comfort, function, and esthetics.

What to avoid before surgery?

It is vitally important to avoid all blood-thinning medications/supplements for 2 weeks prior to surgery. This includes any aspirin or aspirin-containing products as well as any anti-inflammatories such as ibuprofen or naproxen (including Motrin, Aleve, and Advil). It is generally fine to take Tylenol (Acetaminophen). Avoid supplements such as Vitamin E including multivitamins, omega 3 fatty acids such as fish oil, and flaxseed oil. All these medications can contribute to bleeding problems following surgery and can increase the amount of bruising.


The recovery period after jaw surgery depends on the kind of surgery you have.  Some people have lower jaw surgery only, some have just upper jaw surgery, and some people have both jaws operated on at the same time. All our patients are prepared by Dr. Srikanth Yadav Puligilla with the Pre / Post surgical preparation program to enhance quick recovery. After any of these surgeries, your jaw will be wired or firmly banded shut for a period of time. Patients are often required to adhere to an all-liquid diet. After a time, soft food can be introduced, and then hard food. Diet is very important after the surgery, to accelerate the healing process. Weight loss due to lack of appetite and the liquid diet is common but should be avoided if possible. Normal recovery time can range from a few weeks for minor surgery, to up to a year for more complicated surgery.

For some surgeries, pain may be minimal due to minor nerve damage and lack of feeling. Dr. Srikanth Yadav Puligilla will prescribe pain medication and prophylactic antibiotics. There is often a large amount of swelling around the jaw area, and in some cases bruising. Most of the swelling will disappear in the first few weeks. Dr.Srikanth Yadav Puligilla will see his patient for check-ups frequently, check on the healing, check for infection, and make sure nothing has moved. The frequency of visits will decrease over time. Both upper and lower jaw surgery is major bone surgeries, and the recovery period takes months. It is important to be patient and know exactly what to expect, or your recovery may be very frustrating and upsetting for you.
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