From my Ceph am I a candidate for CCW rotation and genioplasty?

[TimMaine]

https://ibb.co/cyTh0Q

Any advice would be much appreciated. I know I would need to speak to a maxillofacial surgeon about this but it would be good to know if a consultation is at least warranted. I’m wondering if I may be a candidate for ccw rotation and genioplasty. My knowledge of these procedures is shaky at best as I’ve only recently been looking into them from what I can find online. Some context…

I actually consulted with an ENT specialist a few months ago (hence the ceph) on the advice of my doctor. I had complained of headaches when I woke up in the morning and he said I may have sleep apnea due to a narrow airway (it’s only now I realise that he could probably have guessed this was the case just from looking at me!). The ENT guy said my airway is only slightly narrowed. He did mention however that I have a recessed lower jaw and that a genioplasty could improve this. He also explained that this may have a slight positive impact on airway size as it would pull the attachments of the tongue muscles (I think?) forward. At the time I was happy that my airway was not an immediate cause for concern and left it at that. However in the interim I’ve been doing some research and I’m thinking it may be worth looking into further…

Please correct me if I’m wrong but what I can gather from my ceph is that:

1) Mandibular plane is excessively steep
2) Lower jaw is recessed
3) Occlusal plane angle is excessive. I measured it at 15 degrees when the norm would be 8 degrees from what I’ve read?
4) Very slight underbite present
5) Front teeth seem tilted forward excessively especially on top. I did have braces in my early teens. Possibly they were pushed forward to compensate for the underbite?

Some other things which I’m thinking might be connected:

1) I cannot close my bite properly as my bottom front teeth extend slightly past their upper counterparts. There is still a visible gap when my teeth are closed.
2) I have a very prominent lower lip. I’m guessing this is due to a combination of the slight underbite pushing the lower lip forward and the fact that the chin is too recessed to give it adequate support from underneath.
3) I don’t really have a defined jaw line even though my body fat percentage is less than 12%.
4) If I completely relax my lips they do not meet, so I think there is some incompetence. Obviously I keep them together out of habit. As a result of this however it seems like I have mentalis strain (kind of a dimply bulk under the lower lip?)
5) My tongue feels too big for my mouth. Sometimes it’s difficult to articulate clearly even if I really concentrate on it.
6) I have post nasal drip. This seems odd as I don’t have any sinus problems or issues with allergies. It's like there's a point at which it's difficult to swallow past.
7) I wake up in the morning with a dry mouth and a headache. For the past month I’ve taken to taping my mouth shut at night and now I feel much better when I wake. No headache or dry mouth. Obviously I had been mouth breathing at night before starting taping.

From what I can gather a genioplasty in isolation would only really mask the problem. Do people think I am a candidate for ccw rotation and genioplasty? I was thinking it could work something like this example I found https://ibb.co/dNoh0Q. Would 20k be too conservative an estimate as to what the whole thing would cost? And if anyone could tell me if factors such as speech difficulties/post nasal drip/mentalis strain can actually be improved by such procedures that would be great.

Apologies for the lengthy post but it’s almost therapeutic to get it all down in writing. It’s all been muddled around in my head for the past while!

[XXRyanXXL]

Your airway seems fine.
You do have a very steep MP angle and OP angles.
You need CCW rotation, either impaction or rotation through downgrafting. This will give you a sharp jawline and project the lower jaw out, you may not even need a genio. If you have photographs that would help.

[TimMaine]

Thanks for the reply. This is a pic from side view https://ibb.co/cbfgC5.

Impaction and downgrafting are new to me. Am I right in thinking that in terms of CCW-R impaction would be when a wedge shape is cut away from the anterior maxilla while downgrafting would be when a bone graft is added to the posterior maxilla?

Well it's good that the airway seems big enough. I still think though it cannot be healthy functionally in terms of musculature etc. to have the jaws in the wrong position. Of course insurance companies would never go for that Could it be done for less than 20k privately in the UK?

[PloskoPlus]

I think you will need genio regardless

[XXRyanXXL]

You are correct.
Impacting the anterior maxilla provides counter-clockwise rotation (and also shortens the anterior facial dimensions, projects the mandible forward and increases airway). It's one of the most stable operations. It's usually done in gummy smile patients, but it can be used also in non-gummy smile. For additional rotation, surgeons can downgraft the posterior by adding porous HA blocks. There was a lot of debate on the long term stability of downgrafting material, but there are a lot of studies done by Larry Worlford to prove the downgraft is stable overtime and actually gets stronger (because the bone grows in the pores).
After looking at your side profile, you could definately benefit from a genioplasty (stay away from silicone implants for various reasons).
I might even put in a recommendation you have an inverted L osteotomy done on the mandible. Put this term into google and search under images and you can see before and after for correction of high MP patients.

[TimMaine]

That's really clear thanks.

Yes I feel like even if the OP was reduced to 8 degrees that still wouldn't bring the chin forward enough without a genioplasty.

Is this an example of an inverted L osteotomy? -  https://ibb.co/dNoh0Q

Difficult to answer I know but any rough idea of cost?