Jaw reconstruction is discussed when the bone of your lower jaw is missing, dead or so badly out of line that it can no longer hold your teeth, carry your bite or support the shape of your face. Five situations bring most people to a reconstructive surgeon: a tumour or large cyst that needs a segment of jaw removed, a fracture that has not united or has united crookedly, bone that has died after radiotherapy or certain medicines, a bone infection that keeps returning, and severe facial injury with lost bone. None of these can be judged from a photograph. Each one is confirmed by examination, dental assessment and imaging, and only then is a plan made.
Sign one: a tumour or large cyst is removed along with a segment of jaw
Some growths in the jaw, both benign and malignant, cannot be scraped out safely. The surgeon has to take the involved segment of bone with a margin of healthy bone around it. That leaves a gap. A gap in the lower jaw is not a small thing, because the mandible is a continuous arch. Once the arch is broken, the two halves drift, the bite collapses, the chin swings towards one side and chewing becomes difficult.
This is the commonest reason jaw reconstruction is planned in advance rather than as an afterthought. Where possible, the removal and the reconstruction are planned together, so that bone taken from your own leg, hip or shoulder blade, with its blood supply attached, can be shaped to rebuild the arch in the same sitting. If you have been told that a segment of your jaw needs to be removed, the reconstruction question should be raised in the same conversation, not months later.
Sign two: a jaw fracture that has not healed, or healed in the wrong position
Most jaw fractures heal after plating or wiring. A few do not. If months have passed since your injury and you still feel movement at the fracture site, still get pain on chewing, or the bone feels as though it has never joined, that is a nonunion. If instead the bone has joined but your teeth no longer meet, your chin looks shifted, or you can only chew on one side, that is a malunion.
Both are reconstruction problems rather than simple plating problems. The old scar tissue and dead bone edges usually have to be cleared, the bone has to be brought back into the right position against your dental bite, and the gap that appears when everything is realigned has to be filled. Small gaps may take a bone graft. Larger ones commonly need bone with its own blood supply.
Sign three: bone that has died after radiotherapy or medication
Radiotherapy to the head and neck reduces the blood supply of the jaw for many years afterwards. A tooth extraction or a small injury in an irradiated jaw can leave bone exposed in the mouth that simply refuses to cover over. Certain bone strengthening medicines used for osteoporosis and for some cancers can lead to a similar problem. The signs to notice are exposed rough bone visible in the mouth, a bad taste or smell, pus, numbness of the lip, or a lower jaw that aches without an obvious dental cause.
Early cases are often managed with dental care, antibiotics and careful cleaning. When a segment of jaw has clearly died, is loose, or has fractured through, removing the dead bone and bringing in living bone with a fresh blood supply is what allows healing to happen. This is a decision taken with your dentist, your oncologist and the reconstructive surgeon together.
Sign four: an infection in the jaw bone that keeps coming back
Chronic osteomyelitis of the jaw shows itself as repeated swelling over the same area, a sinus or small opening that discharges on to the skin or into the mouth, loose teeth, and a course of antibiotics that helps for a few weeks before everything returns. Long standing infection slowly eats away bone, and each flare removes a little more.
When imaging shows dead segments of bone, antibiotics alone rarely settle the problem. The infected bone has to be removed, and the space it leaves has to be reconstructed so that the jaw stays in one piece. If you have had more than two or three flares over the same part of your jaw, ask for a reconstructive opinion rather than another course of tablets.
Sign five: severe facial injury with bone loss
Road traffic injuries, industrial injuries and blast or firearm injuries can take away bone, teeth and the soft tissue over them at the same time. In the early days the priority is your airway, bleeding and life threatening injuries. Once you are stable, the missing structure has to be rebuilt in a planned way, often in stages, because both bone and lining are gone.
If you were treated for a facial injury and were told that further surgery would be needed later, that later stage is jaw reconstruction. It is worth returning for review even if you have adjusted to how things are, because bite problems and asymmetry tend to become harder to correct as scar tissue matures.
What happens when you come for an opinion
An assessment usually includes a careful look at your face and mouth, how your teeth meet, how wide you can open, sensation in your lip and chin, the state of the skin and lining, and your general health, especially diabetes, smoking and nutrition. Imaging such as an orthopantomogram and a CT scan shows the shape and quality of the remaining bone. If a flap is likely, the circulation in your leg or arm is checked as well.
Dr. Ashutosh Shah is a Plastic, Reconstructive and Cosmetic Surgeon in Surat with more than 22 years of surgical experience, holding M.Ch. Plastic Surgery from The Maharaja Sayajirao University of Baroda and DNB from the National Board of Examinations, New Delhi, with microvascular and replantation training. Jaw reconstruction is planned jointly with dental and oncology colleagues, and a written estimate is given before admission.
When you should not wait for an appointment
Some jaw problems are urgent. If you have difficulty breathing, a rapidly spreading swelling of the face or floor of the mouth, trouble swallowing your own saliva, fever with a hot tender facial swelling, or bleeding that will not stop, go to an emergency department now. Spreading infection around the jaw can involve the airway quickly, and that is treated as an emergency rather than something to be booked for next week.
Outside those situations, the sensible step is an unhurried assessment. Reconstruction of the jaw is major surgery with a real recovery, and no operation is without risk. A surgeon should explain what can realistically be restored in your particular case, what will need more than one stage, and what the alternatives are, including doing nothing for the time being.
