Orthognathic Surgery Jaw Surgery

Orthognathic surgery Jaw surgery surger y

Patient information guide

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Content

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Introduction

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Orthognathic procedures

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Treatment schedule

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Agave Clinic

Content

2

3

Introduction

8

Orthognathic procedures

21

Treatment schedule

30

Agave Clinic

Introduction Orthognathic surgery is an unfamiliar term to most people. Therefore they are uncomfortable, even fearful, in considering it as a treatment option. The information in this booklet is designed to take you step by step through the process involved with orthognathic surgery so you understand the entire orthodontic and surgical experience. It is our goal for you to feel completely informed and comfortable with your treatment.

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Combined orthodontic and orth The word orthodontics comes from the Greek word orthos, meaning to straighten, and odons, meaning teeth. Orthodontics is a specialty of dentistry that is concerned with the straightening of improperly aligned teeth. The word orthognathic also comes from the Greek word orthos, meaning to straighten, and gnathos, meaning jaw. Orthognathic surgery thus means “surgery to straighten the jaw”. Orthognathic surgery, also called jaw surgery, corrects the jaws by means of an operation. Such corrections are largely achieved by dissecting the jaw in separate fragments which are then moved into new positions and fixed with plates and screws. All incisions are made inside the oral cavity, avoiding any visible scarring.

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Because moving the jaws also moves the teeth, orthognathic surgery is usually performed in conjunction with orthodontics so that the teeth are in proper position after surgery. In diagnosing your need for orthognathic surgery, the oral and maxillofacial surgeon and the orthodontist will work closely together. The orthodontist is responsible for moving the teeth so they will fit together properly after the jaws have been repositioned. The maxillofacial surgeon is responsible for repositioning the jaw so the teeth and jaws are in proper alignment.

Orthognathic surgery focuses on improving the patient’s appearance as well as the functionality of the jaws and teeth. The aim is to achieve a proper occlusion (the manner in which the upper and lower teeth fit together) and a more aesthetically pleasing face.

gnathic treatment Proper occlusion

Enhanced facial aesthetics

Conclusion

Many malocclusions are correctable by wearing orthodontic braces alone. In some situations, however, the upper and lower jaws are of a different size or shape, or are in an incorrect relationship to one another. In this situation it will be necessary to align the jaws and the teeth. In this way the orthodontic result is not compromised and the optimum result is achieved as far as long-term stability, appearance and function are concerned.

Patients also enjoy an enhanced facial profile, since oral disorders frequently affect facial balance and aesthetics.

In summary, orthodontics correct abnormal tooth position and orthognathic surgery corrects abnormal jaw position.

Some people may consider having cosmetic procedures to enhance their new appearance, such as surgery on the eyes, nose, forehead, chin or neck. You may wish to discuss these options with your surgeon.

Combined orthodontic and orthognathic treatment provides us with the opportunity to improve both functional and cosmetic problems at the same time.

Severe malocclusion (bad bite) may cause many functional problems. You may have already experienced some of the following: •

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•

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inability to chew food properly which compromises digestion speech problems facial muscle dysfunction characterized by headaches, joint pain, etc. periodontal trauma.

Functionality is increased when teeth fit together firmly, making biting and chewing food easier. Surgery also alleviates the grinding and pressure associated with most oral disorders, and prevents further damage to the affected teeth.

Sequence of treatment Combined orthodontic and orthognathic treatment often takes considerable time to complete and therefore requires great motivation and cooperation from the patient. A close liaison between the patient, the orthodontist and the maxillofacial surgeon is also important. Several stages are involved in treatment: •

evaluation and planning

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pre-surgical orthodontics

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surgical treatment

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post-surgical orthodontics

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follow-up visits

Orthognathic surgery 5

About facial harmony While tastes do differ, in orthognathic theory, a number of guidelines describe what are the characteristics of an aesthetically pleasing face.

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Dividing the face in thirds Facial balance typically is assessed by dividing the face in thirds. The upper third is from the anterior hairline to the point on the midline between the eye-brows (glabella). The middle third reaches until a point immediately under the nose (subnasale). The lower third ends on the midpoint of the chin (menton). When each of the thirds is equal, the face is said to be vertically balanced and of ‘ideal’ proportions.

Facial Convexity Additionally, in profile view the face should have a slight degree of convexity as measured from the glabella to the subnasale to the menton. Excess facial convexity, flatness, or concavity is felt to be less ideal. Of course it has to be noted that these guidelines are only idealized concepts. They merely provide a guideline that is not true for every patient. A wide range of faces defy such absolute canons.

Ideal facial convexity

Lack of facial convexity

Excess facial convexity


Orthognathic procedures This section will describe all orthognathic procedures performed by Agave’s team of specialists. In this chapter we discuss the orthognathic procedures according to their anatomical location: the upper jaw, the lower jaw and the chin.

Chapter content Lower jaw surgery retraction advancement

Upper jaw surgery retraction shortening rotation widening

Chin surgery retraction advancement

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Lower jaw surgery Lower jaw surgery is done to correct abnormalities of the lower jaw (mandible), which may be too small or too large. The jaw can be advanced or retracted surgically. Rotation is also possible.

Technical: Sagittal split osteotomy The operation is carried out almost entirely from inside the mouth to minimize visible scars on the skin of your face. It is performed under general anaesthesia.

The most common operation to advance or retract the jaw is called a sagittal split osteotomy (see the technical box). This type of surgery allows for the placement of bone screws or plates. Consequently the jaws don’t have to be wired together at the end of the procedure.

It is then fixed with small screws and sometimes plates. It is often necessary to make a small puncture incision (a few mm long) low down on the side of the cheek to allow the screws to be inserted. These titanium screws, which are left in place permanently, do not set off metal detectors in airports. The lower jaw is split in a vertical (sagittal) plane on each side with a small saw behind the last tooth. The bone is split in a front to back direction so the two pieces can slide along each other and still overlap. The part of the lower jaw with the teeth is moved forward or backward as needed to obtain the desired bite and appearance.

The gum inside the mouth is sutured using dissolvable stitches that may take 3-4 weeks to dissolve Sometimes light elastics are placed between the teeth to guide the jaw into the new bite. Lower jaw surgery may be performed as a single procedure or in combination with other orthognathic procedures.


Retraction of the lower jaw When the lower jaw grows out too far in front of the upper jaw, this results in mandible prognathism. The lower teeth are more pronounced than the upper teeth—a condition called underbite. Orthognathic surgery can be used to slide the lower jaw back.


Advancement of the lower jaw The underdevelopment of the lower jaw is called retrognatia. In this case, the lower teeth are positioned too far behind the upper front teeth (overbite). This condition can be treated by surgically advancing the lower jaw.


Upper jaw surgery Upper jaw surgery is necessary to correct abnormalities of the superior jaw bone (maxilla). The upper jaw may be or narrow, too long, too short, too far forward or too far back to fit the lower jaw properly. In maxilla surgery, the upper jaw can be rotated or repositioned forward, backward, or it can be raised or lowered. Also, asymmetries between different sides of the face can be corrected. Widening of the upper jaw is possible by a surgical split in the midline followed by distraction (see technical box on page 17). Upper jaw surgery is performed mainly by utilizing a bone dissecting procedure called ‘Le Fort I osteotomy’ (see technical box).

Technical: Le Fort I osteotomy A Le Fort I osteotomy is the most commonly used procedure to make bone incisions in the upper jaw. This procedure is performed under general anaesthesia. The operation is carried out entirely inside the mouth. A Ushaped incision is made through the gums above the upper teeth to gain access to the jawbone. The gum is then raised off the bone. The upper jaw incisions are made with highly specialised tools, which allow for a controlled parting of the bone. Additional bone is removed if the upper jaw is to be shortened. Bone can be added if necessary to lower the jaw and make it longer (bone graft).


The upper jaw bone is then moved into its final position (planned prior to your surgery) and held in place with tiny titanium plates and screws, which are left in place permanently. The gums are stitched back into place with dissolvable stitches. These stitches may take three to four weeks to dissolve. After the bones heal together, the jaw regains it’s normal strength.

Advancement of the upper jaw The underdevelopment of the upper jaw is called horizontal maxillary deficiency. The lower teeth are in front of the upper teeth— a condition called underbite. These patients may have a sunken in or very flat face. Facial contour and dental occlusion can be harmonized with the advancement of the upper jaw by cutting it horizontally and moving it forward.


Shortening of the upper jaw Vertical maxillary excess is when the upper jaw (maxilla) has grown too far down. When smiling, too much gingiva is visible (gummy smile) and often there are difficulties in putting the lips together. Not only is this situation cosmetically undesirable, it can also result in sore, red, bleeding gums from chronic exposure to air. This problem can be orthognathically corrected by excising a segment of upper jaw, therefore elevating the level of the teeth.


Rotation of the upper jaw When only the back portion of the upper jaw is overdeveloped vertically, this will result in the inability for the front teeth to meet— a condition called ‘open bite’ (apertognathia). As the back portion of the upper jaw grows vertically downward, the lower jaw will open in a clockwise direction. This explains why open bite patients have a long facial appearance. There is little or no ability to “bite” using the front teeth. This makes eating a challenge, and causes problems with swallowing, speech, and often resulting in red swollen gums due to chronic air exposure. This condition can be corrected by removing a wedge of bone in the upper jaw.


Widening of the upper jaw When the upper jaw is too narrow, this results in what is called a transverse maxillary deficiency. This narrowness can cause the upper teeth to bite inside the lower teeth (crossbite), crowding of the teeth, or black corridors upon smiling. The patient may have a smile that shows mostly the two prominent front teeth, with the others in shadow (buccal corridors). Also crossbites can have a pronounced effect on the overall facial appearance. With a distraction procedure the upper jaw can be widened until it fits around the lower jaw. Surgery is used to separate the two halves of the upper jaw and a distraction device is placed into the jaw. The patient has to turn the expansion screw of the device every day for about two weeks. New bone fills in between the gradually widened two halves. Orthodontic treatment will close the gap created by the distraction (for more information see the technical box on the next page).


Technical and practical: Distraction of the upper jaw The surgical procedure to make the bone incisions in the upper jaw is the same as previously explained in the Le Fort I osteotomy of the upper jaw. However, to create two halves one more incision is made vertically on the midline of your upper jaw. A distraction device is placed with a little plate on each side of the palatal bone of the upper jaw. At the end of the operation, a small blocking screw is inserted.

has a center screw that must be turned with a key. The divider is “activated” by placing the key into the key-hole in the center screw and then gently pushing toward the back of the mouth. Each day, we open the palate ± 0,5 mm. So, after 10 days, we can expect an opening of 5 mm between Before distraction. the two front teeth. The screw usually has to be turned for 1 to 3 weeks depending on the amount of widening needed. Consolidation phase Once the widening of the palate is achieved, the fixing screw is placed again. The distractor should be kept firm and immobile in the mouth for 3 to 5 months. This allows time for new bone to form and ensures that the widening will not relapse.

Activation phase A new consultation is scheduled a week later. The blocking screw will be removed and the activation of the device can start. The distractor

After the activation phase.

In this phase, the orthodontist may begin treatment to close the gap between the front teeth. Later on, the plates on both sides of the palate will be removed surgically under local anaesthesia. After orthodontic treatment.


Chin surgery Some faces have a poor projection of the chin, an overprojected chin, or a problem with the width or height of the chin. Chin surgery can be used to improve the appearance of a person’s chin. A particular process, known as a sliding genioplasty, involves separating a horseshoe-shaped piece of the chin bone from the lower jaw and sliding it either backwards or forwards, and finally fixing it in place using titanium screws. The profile of a patient can be significantly altered with a chin procedure. This, in turn, has a significant effect on overall facial symmetry. Men and women look best with certain types of chins. A small chin can make a large nose look even bigger, or conversely, a large chin may even make a large nose look tiny for the face. This chin/nose relationship must be harmonious. A central consideration in deciding if chin remodeling alone is appropriate is whether dental occlusion (the way your teeth meet) is correct or not.


Technical: Sliding genioplasty Chin surgery is carried out under a general anaesthetic and takes about one hour. An incision is made inside the mouth, so no scar will be visible on the outside. The chin is cut from back to front on both sides, using a powered saw with a special blade to separate the edge of the chin. The bone segment is then slid forward or backward, or any direction desired. If needed, a segment of bone can be removed. The piece is then secured with permanent titanium miniplates and screws, which will never be removed.

If dental occlusion is satisfactory, the appearance of the chin can be dealt with by chin surgery alone. If it is not, a combination of upper or lower jaw surgery may be needed.

Advancement of the chin If only the lowest third of the face is sunken in, yet the occlusion is normal, a chin advancement may be the solution. Especially in men, it can help to make the face look ‘stronger’.


Retraction of the chin In patients with an overprojected chin and a normal occlusion, the chin as a separate entity can be retracted.


Treatment schedule 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.

Treatment schedule

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Evaluation and treatment planning 1 week

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Pre-surgical orthodontics

12-18 months

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Surgery

2 weeks

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Post-surgical orthodontics

3-9 months

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Follow up visits

6 months

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Evaluation and planning

During your first visit, a set of diagnostic records will be made to determine the nature of your problem and what can be done to correct it. After processing and analyzing these records, we will meet you to discuss your treatment options. The following explains the individual records that may be taken and their purpose. Photographs

Cephalometric radiograph

Panoramic radiograph

Frontal and profile facial photographs are an essential part of the overall planning of the case. These images 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.

This side view radiograph of the face allows us to compare your tooth and jaw relationships to normal or ideal measurements. Computerized analysis permits the prediction of planned bone movements and resulting soft tissue response through the merger of the facial pictures with the cephalometric radiograph.

The panoramic radiograph is a composite view of the teeth as well as both jaws. In one film, it shows us if you have the normal number of teeth, wisdom teeth, or impacted teeth.


Optional: Conebeam CT

Dental models Dental models will be used to study the problems that exist at the beginning of the treatment and are used for reference during pre-treatment planning.

A new software has been developed by Medicim in Belgium, called Maxilim. Using the Maxilim software we can make virtual incisions to move the jaws and chin as planned, then show the potential result to the patient. Small corrections can be made on the computer during the consultation. If the patient likes the result, we send the data to Belgium. After a week, we receive a set of acrylic templates that will enable the surgeons to follow the computer plans precisely during the actual procedure. The use of Maxilim software permits us to predict the facial changes which you might expect with treatment. To be able to do this, a conebeam CT scan will need to be taken. A conebeam CT has the advantage of extremely low radiation dosage plus the fact that the patient is in a sitting position, which gives a more natural appearance of the soft tissues. Please note that the use of Maxilim is not standard and will increase the cost of your treatment.


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Pre-surgical orthodontics

Pre-surgical orthodontic treatment often involves fixed brace treatment lasting 12-18 months and is essential for the stability of the result. The purpose of orthodontic therapy is to level and align the teeth so that once the surgeon moves the jaw bones, the teeth will fit together. Orthodontists are specialised dentists that are typically required to complete an additional three to four years of postdental school education before becoming a certified practitioner of orthodontics.

Tooth irregularities are treated using corrective appliances known as braces. Braces are made from wires and springs attached to tiny metal plates or a plastic mould. Braces use gentle pressure to slowly shift teeth into their new positions. Modern orthodontic treatment uses very mild pressure to reduce the discomfort. Also, modern braces are less noticeable than old-fashioned braces. The braces remain in position during the operation to aid the surgeon in positioning the jaws correctly.


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The surgery

Pre-Operative Instructions •

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You should not eat or drink anything 8-10 hours before surgery.

The operation •

Arrange the necessary time off from work or school. Most patients will need one to four weeks of convalescence. To avoid pulling clothes over your head postoperatively, bring some button-down or zippered shirts. We strongly advise you to stop smoking three weeks before surgery, as smoking counteracts wound healing.

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You will be admitted to the hospital the morning of your scheduled surgery. The length of your surgery depends on the procedure being performed, but normally ranges from 2 to 5 hours. Orthognathic surgery is performed under general anaesthesia. 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.

Complications The possible complications include: •

Bleeding.

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Infection.

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Nerve injury (permanent numbness of the lip, tongue, cheek, etc.). Relapse or return to original jaw positioning.

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Damage to teeth.

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Scarring.

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Temporomandibular (TMJ, or jaw joint) problems. Nasal airway obstructions. Non-union (inadequate closure) of the bone. Sinusitis (swelling of the nasal sinuses).

All of these are rare.


Post-operative instructions: •

Cooling: During the first postoperative hours a mask with a constant temperature of 15 degrees Celsius will cool the surface of your face and keep bruising and swelling to a minimum. This will add to your comfort and assist you in a more rapid recovery from surgery. Nevertheless you should be prepared to be seriously bruised and swollen for about one week.

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Pain: Postoperative pain normally is surprisingly mild. We will provide you with painkillers for the first few days.

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Food: It is a good idea to only eat soft foods for the first few weeks. After about a month, patients can switch to foods with regular consistencies.

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Oral hygiene: We will provide you with a post-surgical antiseptic mouth wash, with which you should rinse as directed until you can brush your teeth normally. However, you should try to switch to fully cleaning your teeth with a toothbrush, toothpaste and dental floss as soon as possible.

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charged from hospital by your surgeon one or two days after surgery. If alone, one of our nurses will accompany you to your hotel. You will have daily revisions in Agave Clinic during your stay in Marbella. •

Mouth opening: Immediately after the operation you should actively exercise your jaw (using your chewing musculature, not by manipulating your jaw with your hands). Practice gently opening your mouth and moving your jaw from side to side. This ensures a speedy recovery of normal jaw function.

Aftercare: Normally, you will be dis-

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Our team is permanently at the patient’s disposal. Contact with our specialist during office hours can be made by telephoning our direct line. After hours this contact is available through the 24-hour emergency services of the USP hospital. Before you leave Marbella you will be seen again at Agave Clinic. If necessary, sutures will be removed 5 to 7 days, before leaving Marbella.

Working: About two to three weeks after surgery you can start working again. The swelling will disappear completely in about six months.

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Sports: Refrain from contact sports for 6 weeks.

The cooling mask against pain and swelling. 26 Patient information guide

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Post-surgical orthodontics

Usually a period of post-surgical orthodontics are required after the surgery to fine-tune the bite. This finishing period usually lasts between 6 to 9 months. Retention Three weeks after surgery, the orthodontist continues with the treatment plan. The tooth arcs were already in line, but now the relationship between them has been normalized by the surgeon. The orthodontist will now work to finetune the bite so all the lower teeth make contact with the corresponding upper teeth.

Usually 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.

Fixed retainer for the lower teeth.

Retention is a 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 use of your retainer to sleeping only. Keep in mind, however, that the more the retainers are worn, the less chance there is of teeth moving out of place.

Removable retainer for the upper teeth.


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Follow up

One, three and six weeks after surgery we would like to check your bite and evaluate your healing progress Once your treatment is complete, a set of final records will be taken at Agave Clinic. 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. Six months later one more visit to the orthodontist is necessary to check your bite and to adjust your retainer (for the last time!).


Frequently asked questions Do I need to follow a special diet after the surgery?

Will my jaw break more easily after such an operation?

Is orthognathic surgery painful?

You should only eat soft foods for the first weeks. After about a month, patients can switch to normal foods.

No. Once the bone is completely healed, your jaw is as strong as before.

The postoperative pain is remarkably mild and can be managed with standard painkillers. The swelling, however, causes discomfort for 1 to 2 weeks.

In principle, patients can eat anything they want to, just not always in the way that they’re used to. Food can be finely shredded with a food processor, blender, or mixer.

When can I start practitioning sports? Bone healing will take 6 weeks. After that the bone will be as strong as before the operation and you can practice any sports you like again.

Will the plates and screws be removed? No. Plates and screws are usually not removed, only in the rare case of infection.

When can I start working again? Most people start working after two to three weeks.

Do the plates activate metal detectors? No, they are too small for that.

How long will the swelling last?

Is orthognathic surgery dangerous? This type of surgery, in the hands of an experienced team, is very safe and has a very predictable outcome. In very rare cases a second surgery in the first week after the initial intervention is necessary, because the position of the jaws is not as planned. Apart from complete sensory nerve damage, resulting in permanent numbness in half of the lower lip and chin (which is extremely rare), no major complications exist.

About 90% of the swelling will subside in 3 months. But it takes up to 6 months for the swelling to disappear completely.


Agave Clinic Agave Clinic is an international pioneering centre dedicated to complete oral and facial reconstruction. Our goal is to achieve natural looking beauty by creating facial harmony.

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To create facial harmony you need to be able to manage not only the facial skin, but also the facial bone and teeth. In our centre we perform: •

dentistry and implants,

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orthodontics,

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maxillofacial surgery,

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and facial plastic surgery.

Because we have this complete team of experts for dentistry and facial surgery under one roof you can be sure that all possible options will be taken into consideration and you will get the most comprehensive treatment plan options to solve your problems. It is the wide variety of treatments offered in combination with this close collaboration between professionals that makes Agave Clinic really unique. Agave Clinic is truly international because of its multilingual staff and the proximity to an international airport. Our staff are fully conversant in English, German, Spanish, Dutch and Portuguese. For all other languages we can provide an interpreter. Agave Clinic is only a 25 minute taxi drive to Malaga International Airport. Each month we also have consultations in London, Blaricum and Papendrecht (the Netherlands). In Agave Clinic´s state-of-the-art facility, you are sure to receive first-rate service in a modern atmosphere. Here our experienced team of professionals utilise the latest technologies for a detailed examination and radiological assessment. Orthognathic surgery 31

Surgeries requiring general anaesthesia take place in the adjacent USP Hospital. Agave Clinic not only cooperates closely with the USP Hospital, but also serves as its maxillofacial and dentistry department. This hospital houses a team of more than 150 medical specialists, with six operating theatres, an intensive care unit as well as an Emergency Services department. Agave Clinic can be contacted 7 days a week, 24 hours a day, through the USP Emergency Services.

The founding of Agave Clinic Agave Clinic was founded by Dr. Bart van de Ven (the Netherlands) and Dr Daniel Simon (Brazil). They got to know and appreciate each other’s expertise during two missions in Vietnam and Kenya for the Cleft Surgery Organization (CSO). CSO is another initiative of Dr Bart van de Ven. Its mission is to provide free cleft surgery for affected children from poor families (www.cleftsurgery.org). Dr Bart van de Ven and Dr Daniel Simon not only shared their passion for the Cleft Surgery Organization, but also shared the dream of starting an all-round clinic for facial surgery and dentistry in Europe, where patients could access quick and superior treatment options.


Patient coordination Our patient coordinator, Lilia Koss, looks after patients that have to stay in Marbella a bit longer after their surgery. She assists with accommodations, recommends airlines and organizes your taxis and appointments.

Flying to Malaga

Hotels in Marbella

Our patient coordinators will suggest airlines from your country to Spain. From Agave Clinic to Malaga international airport is only a 25 minutes taxi drive. More than 60 airlines fly to Malaga.

We will help you find your preferred accommodations nearby and assist with reservations. Room service, internet and other amenities are available upon request. Prices may vary according to the season.

panion; patients who travel alone may be recommended an extended hospital stay or nursing care in the hotel (additional fees involved).

Aftercare in Marbella

Each month we have a day of consultations and check-ups in the UK (London) and in the Netherlands (Blaricum and Papendrecht). You can make an appointment by contacting Agave Clinic in Marbella. If you’re interested in dental implants and have a panoramic x-ray it would be very useful to bring it with you.

We’ll pick you up from the airport and bring you back for free. About 40% of the population of Marbella is of non-Spanish origin so you’ll find English-speaking people everywhere.

Our personal care and attention continues long after your procedure. During the first week post-op, you will have daily re visions in Agave Clinic. Once you return home, we hope to arrange for 3-month, 6-month and 1-year evaluations with the surgeons. It is highly recommended to our surgical patients to come with a com-

Consultations and checkups abroad


Contact information Address:

Av. Severo Ochoa, 24. Marbella, Spain (next to USP hospital)

Website:

www.agaveclinic.com

Email:

[email protected]

Tel Agave clinic:

+34-952.864.191

Tel USP Hospital:

+34-952.774.200

Each month, we also have a day of consultations and check-ups in the United Kingdom (London) and in the Netherlands (Blaricum and Papendrecht). You can make an appointment by contacting Agave Clinic in Marbella.


If you have any questions, please don’t hesitate to contact us.

Orthognathic Surgery Jaw Surgery

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