"I recall going out bicycling that morning and going through the typical feelings of how it would be more comfortable lying in bed," he says. "But I don’t recall the actual collision."

Fortunately, he was wearing the Bell Biker helmet that he bought more than 20 years ago. That spared him from serious brain injury and possibly saved his life. Still, his injuries were extensive enough that he was taken by helicopter to The New Jersey Trauma Center at University Hospital. He had a lacerated liver, a bruised kidney, and three fractured ribs. Those injuries were treated, and the next day, when he was medically stable, attention turned to repairing the man’s face.

Mr. Heberling had one of the most severe types of facial fractures, a Le Fort III; his upper jaw was broken in two places and his lower jaw was literally split down the middle. He lost eight front teeth in the accident, six on top and two on the bottom. As Mr. Heberling was about to discover, facial reconstruction can be a slow but necessary road to healing.

The Many Faces of Facial Trauma

Facial reconstruction following an accident such as Mr. Heberling’s can be complex. There’s much more than appearance to consider, such as damage to the jaws and teeth, which can compromise a person’s ability to chew and to speak correctly; soft tissue injuries, and injuries to the facial nerves or salivary glands. That’s why an oral and maxillofacial surgeon’s interdiscipinary training is so valuable.

The average person probably associates oral surgery more with removing wisdom teeth than with treating head and facial injuries. However, oral and maxillofacial surgeons have a unique blend of dental and surgical training. After completing dental school, they undergo a four-year hospital-based residency where more than 30 percent of their training involves trauma management. Some, such as Dr. Vincent Ziccardi, Mr. Heberling’s surgeon, also earn a medical degree.

"With a facial trauma, my job is to take what’s been injured and restore it as close to the original condition as possible," says Dr. Ziccardi, chief of dental medicine at University Hospital and chairman of the Department of Oral and Maxillofacial Surgery at UMDNJ-New Jersey Dental School.

Facial traumas run the gamut from a fractured cheek bone to "knocked out" teeth to a badly cut lip. Many are caused by automobile accidents, sports injuries, assaults, or falls. While not all injuries are of equal severity, even seemingly minor facial lacerations can warrant medical attention because of their location near nerves or for cosmetic reasons.

A facial trauma patient’s immediate medical needs can be taken care of in an emergency room or sometimes at an oral surgeon’s office. But after the initial treatment, additional post-trauma facial reconstruction may be necessary.

"It varies case by case. Some patients might need scar revisions or dermabrasion," says Dr. Ziccardi. "On another level of reconstruction, dental rehabilitation is what it takes to make the patient whole."

Mr. Heberling fell into the second category. The day after the accident, Dr. Ziccardi performed open reduction and rigid fixation of the facial fractures to reposition the cyclist’s fractured jaws. Because a broken jaw can’t be held in place with a cast as a broken arm can, oral surgeons use tiny plates and screws to stabilize the fracture; sometimes the patient’s mouth is wired together.  As Mr. Heberling recovered from the surgery, he found both: His jaws were wired, and a plate-and-screw combination held his chin together. Gradually, the "hardware" was removed, and a set of partial dentures was made for Mr. Heberling by Dr. Cosmo De Steno, a prosthodontist and associate dean of clinical affairs at New Jersey Dental School.

Partial dentures are a temporary solution for Mr. Heberling. By summer, he’ll have dental implants to replace his eight missing teeth. Implants are artificial tooth roots that are surgically placed into the jaw to hold replacement teeth. The implant process takes between three and six months, and for Mr. Heberling, it began in February with a bone graft.

"A good bony structure and healthy gums are essential to an implant’s success, because in time the jaw bone attaches to the implant to hold it in place, a process known as osseointegration," says Dr. Ziccardi. "Bill needed a bone graft to replace areas of jaw bone that were missing because of the accident." 

Once Mr. Heberling’s bone graft healed, the first phase of dental implantation began: placing the artificial root into the jaw and covering it with gum tissue. Once osseointegration has occurred, the root is uncovered, and a post is attached and then capped with a permanent crown.

Mr. Heberling’s accident has left him with a stronger faith and an even greater appreciation for his four children and his wife. He also is thankful for Dr. Ziccardi and the other doctors at University Hospital who "did an amazing job putting me back together."

Corrective Jaw Surgery: Not for Trauma Only

Mr. Heberling had surgery to repair his fractured jaw bones. But corrective jaw surgery is not reserved for trauma cases. Many people have these corrective procedures to enable them to eat more easily, speak more clearly, and look more "in balance."

"‘Orthognathic’ is a very precise word -ortho means straight and gnathic refers to the jaw," says Dr. Ziccardi. "There are a number of ways a person’s maxilla or mandible the upper and lower jaws can grow unevenly. There can be an underbite, an overbite, or a crossbite. For others, the chin is either underdeveloped or overdeveloped. Through surgery, the jaw or chin can be repositioned."

According to the American Association of Oral and Maxillofacial Surgeons, approximately 5 percent to 7 percent of Americans have dentofacial deformities involving the jaw.

A general dentist is usually the first healthcare professional to discover a dentofacial deformity, but many people can see that their jaws are not aligned properly by looking in a mirror. There are some other symptoms, as well.

"These patients may have difficulty chewing or be unable to bite into a sandwich," notes Dr. Ziccardi."There can be excessive mouth breathing, which can be drying to the gums and lead to gingivitis."

The dentist makes a referral to the oral surgeon, who works in tandem with an orthodontist to develop a treatment plan. At the New Jersey Dental School, the Center for Dentofacial Deformities is dedicated to helping people with misshapen jaws. Some people will need surgery and others are helped by braces alone, but in both instances, orthodontics is involved.

"Most patients will wear braces for 6 to 12 months before surgery to align the teeth and to optimize surgical movement,"says Dr. Ziccardi, "and then for about another six months afterward to stabilize the teeth and jaw bones."

Corrective jaw surgery is most commonly done when patients are in their late teens or 20s when jaw growth is complete. Using digital imaging technology, the oral surgeon can show the patient a reasonable estimate of what he or she will look like after treatment is complete.

Orthognathic surgery is done in a hospital, and depending on the procedure or procedures, takes from two to eight hours. At University Hospital, a "bloodless" technique, hypotensive anesthesia, is used during orthognathic surgery to reduce blood loss. It involves a controlled lowering of a patient’s mean arterial pressure during surgery through various agents, explains Dr. Ziccardi, who is affiliated with The University Center for Bloodless Surgery & Medicine at University Hospital. Orthognathic surgery typically requires an overnight hospital stay, followed by one to two weeks of recovery time.

In the past, the weeks following orthognathic surgery were considered the most difficult part. The patient’s teeth and jaws were wired together for several weeks to support the surgical movement. This was uncomfortable and, with the patient able to have only liquids, sometimes resulted in unwanted weight loss.  

Today, tiny plates and screws are used that fixate the facial bones in a shorter amount of time and with a quicker return to a normal soft diet.

Once the post-surgical orthodontic work is complete and the braces are taken off, the orthognathic patient has a more balanced-looking face and a better ability to chew and speak normally.

For more information about orthognatic procedures, contact the Center for Dentofacial Deformities at (973) 972-2444.