Jaw Advancement to improve breathing

[dammit_daniel]

I would do that FIRST since it's consistent with helping breathing and probably a better chin aesthetic.  Save the ENT tongue cut option for later.

I thought the genioglossus advancement was always used for people with apnea/narrow airways, my limited understanding was that moving the genioglossus moved the hyoid and base of tongue forward. But my ENT is saying that the genioglossus advancement only moves the lower base of tongue forward and won't do anything for upper tongue base collapse, which is what he has diagnosed me with from his endoscopic inspection & cone beam scan. He thinks that a midline glossectomy has a 70% chance of fixing my issue. I was sceptical of the ENT dismissing the genioglossus advancement though, him being an ENT he doesn't perform that surgery so I thought of course he would dismiss it. He later also revealed he didn't want to work in the other surgeons hospital and that the logistics of both the surgeries at once might be to hard..so I was even more sceptical of him now and his tongue surgery suggestion. He did seem genuine in his advice though. I think he's only performed the tongue surgery 5 times, but he claims to have a 100% success rate at curing apnea.

It's all quite hard to make a good judgement call. I could potentially even look for another sleep surgeon ENT, although they're quite hard to find and would mean an even longer wait for surgery with intial consultations etc. I'm just talking out loud here by the way.

[dammit_daniel]

What are the meassurements of the min-area, and the volume? Dö you have these meassurements from pre-op as well?

Advancing the genioglossus will of course do something as it's attached to what you wish to move. Question is how much and if it's worth it. First would be to know what kind of advancement and surgery you can be offered.

Hey, I can get you some measurements on the weekend, I would appreciate your advice, I think we had a good medical article with healthy airway areas. I might dig that up.

By the way my old jaw surgeon is not even keen to do the genioglossus advancement unless I get a sleep study AND an ENT refferal. And my ENT is not backing the genioglossus advancement. And my jaw surgeon doesn't want to make any calls if the genioglossus advancement is appropriate for my issue.

I previously discussed the surgery with the jaw surgeon. It would be the surgery where a rectangle is cut below your lower teeth, which tries to capture where the genioglossus muscle is attached to your chin, and the rectangle is advanced forward and turned 90 degrees and screwed into your chin. I think I read somewhere the advancement is usually 6mm, or the width of your chin bone.

Does this improve chin aesthetics somehow? Does the labial fold become less pronounced or something? otherwise I can't imagine how the chin would look better?

[kavan]

Well, you are going through a logical thinking process in this regard. I think it is good, in this situation to be somewhat skeptical and you are clear in expressing what you are not so sure of. I've done some reading on this. But of course, it's not a subject I'm highly familiar with either. What he's telling you is that you have a 'FAT' tongue and he can remove part of it.

His advice is to have HIS surgery FIRST or INSTEAD of chin advancement. Mine is to have the chin advancement FIRST and his surgery later IF the chin surgery does not assist in better breathing. Now, ASSUMING that chin advancement would yield an aesthetic improvement whether or not it also improved breathing in your case, my decision analysis goes something like this:

Chin surgery first. If you have the chin surgery first, there are 2 basic outcomes:

1: Aesthetic improvement with NO improvement to breathing.

2: Aesthetic improvement WITH improvement to breathing.

Either way, you get aesthetic improvement from it. IF #1, you confirm his diagnosis is right and you then STILL have option of having his surgery. IF #2, you confirm, you don't need his surgery.

Tongue surgery first.

1: Improvement to breathing but no aesthetic benefit.

2: No or not much improvement to breathing and no aesthetic benefit.

Either way, there is no aesthetic benefit to this surgery. IF #1, where it did improve breathing, you have to ask yourself if you would later want the chin surgery for more aesthetic benefit. IF #2, no breathing benefit, you would then later need to explore the chin surgery for better breathing.

So it DEPENDS on what is WORSE to you to find out FIRST and whether or not you would want the chin surgery just for aesthetic improvement.

Would it be worse to you to find out first the tongue surgery did not improve your breathing and just resolved to having to get the chin surgery later because it didn't work OR would it be worse to you to get the chin surgery first and find out that although it improved your aesthetic, it did not improve your breathing.

To me, personally, I would go for the chin surgery FIRST, which has an aesthetic benefit, on the CHANCE that it could also improve breathing. It would be WORSE to ME to have the tongue surgery first and find out THAT did not improve breathing than to find first that the chin surgery did not improve breathing and especially so IF I would get the chin surgery ANYWAY for aesthetic improvement.

Keep in mind that it's a decision under UNCERTAINTY and the choice resolves to asking yourself what you would rather NOT find out FIRST.

Here are some links I found about tongue surgery and also a device to try which might help determine if the tongue is the culprit.


https://www.fauquierent.net/botcoblation.htm

https://www.verywellhealth.com/tongue-stabilizing-device-for-treating-sleep-apnea-3015243

[dammit_daniel]

Thanks for your analysis of my situation Kavan.

Concerning aesthetic improvement i believe the surgery i discussed with my suegeon was the one here

https://www.google.com/search?q=genioglossus+advancement&safe=off&client=ms-android-samsung&prmd=ivn&source=lnms&tbm=isch&sa=X&ved=2ahUKEwiKpbiLltPiAhWOfH0KHUAWAr0Q_AUoAXoECA4QAQ&biw=360&bih=560#imgrc=i89Ljo5HdZ46mM

Where just a rectangle is cut out and brought forward. I'm not really expecting any improvement in aesthetics like a chin advancement.

That tongue device is actually a really good idea!. Not even my ENT told me about it. I brought one a few years ago before my MMA surgery, but it didn't help. Now i have been using it again the past 2 days and it works very well (post MMA) So excellent suggestion there! I guess that tells me the tongue is the culprit like you said. Pretty annoying though to not have all my airway problems fixed by MMA. I thought MMA was the ultimate solution. Maybe my airway is just that screwed up. Could be related to a connective tissue disorder I'm having checked out...a doctor told me a heart arrhythmia could be a clue to all this.

The tongue device also causes my teeth to press on my tongue. I can feel the pressure on my teeth, it might not be a great long term solution in terms of jaw relapse.

[Dogmatix]

Hey, I can get you some measurements on the weekend, I would appreciate your advice, I think we had a good medical article with healthy airway areas. I might dig that up.

By the way my old jaw surgeon is not even keen to do the genioglossus advancement unless I get a sleep study AND an ENT refferal. And my ENT is not backing the genioglossus advancement. And my jaw surgeon doesn't want to make any calls if the genioglossus advancement is appropriate for my issue.

I previously discussed the surgery with the jaw surgeon. It would be the surgery where a rectangle is cut below your lower teeth, which tries to capture where the genioglossus muscle is attached to your chin, and the rectangle is advanced forward and turned 90 degrees and screwed into your chin. I think I read somewhere the advancement is usually 6mm, or the width of your chin bone.

Does this improve chin aesthetics somehow? Does the labial fold become less pronounced or something? otherwise I can't imagine how the chin would look better?

Yes, there are some articles where airway meassurements are compared between OSA and and control group. Note that those studies does not say what meassurements healthy airways have. You can have small meassurements and have no problems, and big meassurements and have big problems. But there is a causality.

If you have your cbct raw files I would find it interesting to load it up in a dicom viewer and see what it looks like. On the study we've discussed earlier, the control group had a mean cross section area of 253+-76, while OSA had 159+-74. I can't see any area or volume meassurements on your pictures.

[kavan]

Thanks for your analysis of my situation Kavan.

Concerning aesthetic improvement i believe the surgery i discussed with my suegeon was the one here

https://www.google.com/search?q=genioglossus+advancement&safe=off&client=ms-android-samsung&prmd=ivn&source=lnms&tbm=isch&sa=X&ved=2ahUKEwiKpbiLltPiAhWOfH0KHUAWAr0Q_AUoAXoECA4QAQ&biw=360&bih=560#imgrc=i89Ljo5HdZ46mM

Where just a rectangle is cut out and brought forward. I'm not really expecting any improvement in aesthetics like a chin advancement.

That tongue device is actually a really good idea!. Not even my ENT told me about it. I brought one a few years ago before my MMA surgery, but it didn't help. Now i have been using it again the past 2 days and it works very well (post MMA) So excellent suggestion there! I guess that tells me the tongue is the culprit like you said. Pretty annoying though to not have all my airway problems fixed by MMA. I thought MMA was the ultimate solution. Maybe my airway is just that screwed up. Could be related to a connective tissue disorder I'm having checked out...a doctor told me a heart arrhythmia could be a clue to all this.

The tongue device also causes my teeth to press on my tongue. I can feel the pressure on my teeth, it might not be a great long term solution in terms of jaw relapse.

I was thinking in terms of sliding advancement genio for aesthetic improvement. It does something in favor of breathing.  That 'electrical plug in' genio does not look like it would do much aesthetically though. Glad the tongue device info was helpful. I just Googled around and found it. I guess the airway can be open enough but the tongue could block the air passing through it.

[dammit_daniel]

I was thinking in terms of sliding advancement genio for aesthetic improvement. It does something in favor of breathing.  That 'electrical plug in' genio does not look like it would do much aesthetically though. Glad the tongue device info was helpful. I just Googled around and found it. I guess the airway can be open enough but the tongue could block the air passing through it.

I've read articles saying that large sliding genio's do help breathing, in order of 10mm+. I've also read other articles that say sliding genio's aren't as effective as genioglossus advancement because they don't capture the genioglossus muscle, because it attaches to the chin closer to ones teeth. 
I also came across this variation of a genioplasty called a mortized genioplasty. You might of heard of it.

https://ars.els-cdn.com/content/image/1-s2.0-S1010518207000546-gr1.gif

Which apparently gives you the advantage of capturing the genioglossus muscle as well as advancing the chin to give a better aesthetic. I'm not sure how common this technique is though. Also apparently whenever you make a cut to capture the genioglossus muscle you risk damaging the roots of the lower teeth, and they can potentially be lost. Just some things I thought I would share from my research.

[dammit_daniel]

Yes, there are some articles where airway meassurements are compared between OSA and and control group. Note that those studies does not say what meassurements healthy airways have. You can have small meassurements and have no problems, and big meassurements and have big problems. But there is a causality.

If you have your cbct raw files I would find it interesting to load it up in a dicom viewer and see what it looks like. On the study we've discussed earlier, the control group had a mean cross section area of 253+-76, while OSA had 159+-74. I can't see any area or volume meassurements on your pictures.

The cbct is quite a few gigabytes in size Dogmatix. I can just show you screenshots.

Thanks for digging the areas up.

My narrowest area behind the tongue is 138mmsq

https://imgur.com/a/0RZk63a

It's something like 5.5mm anterior-posterior width at the widest part of the narrowest area behind the tongue shown.

I can't believe I had bimax and I still am below the OSA airways area avg! 

[Dogmatix]

The cbct is quite a few gigabytes in size Dogmatix. I can just show you screenshots.

Thanks for digging the areas up.

My narrowest area behind the tongue is 138mmsq

https://imgur.com/a/0RZk63a

It's something like 5.5mm anterior-posterior width at the widest part of the narrowest area behind the tongue shown.

I can't believe I had bimax and I still am below the OSA airways area avg! 

Just a note, these figures don't diagnose sleep apnea, it just shows some causality that was found in in that report. But as you also have problems it may justify your concern. Just want to say so you don't get stressed up by some numbers in a report, your experience is what's most important. But I agree, the anticipated 14mm advancement is significant and I've heard people with
OSA who only have about 10mm advancement with good result.

Do you have your cbct from before surgery so you can see the main cross section and volume there as well?

What dicom viewer do you use? The one I use don't offer support to automatically find min/max area and calculate the volume.

Yes I know, the files are large. Figured it shouldn't be a problem on Google drive or something. But it doesn't matter, seems like you find the interesting parts yourself.

[kavan]

I've read articles saying that large sliding genio's do help breathing, in order of 10mm+. I've also read other articles that say sliding genio's aren't as effective as genioglossus advancement because they don't capture the genioglossus muscle, because it attaches to the chin closer to ones teeth. 
I also came across this variation of a genioplasty called a mortized genioplasty. You might of heard of it.

https://ars.els-cdn.com/content/image/1-s2.0-S1010518207000546-gr1.gif

Which apparently gives you the advantage of capturing the genioglossus muscle as well as advancing the chin to give a better aesthetic. I'm not sure how common this technique is though. Also apparently whenever you make a cut to capture the genioglossus muscle you risk damaging the roots of the lower teeth, and they can potentially be lost. Just some things I thought I would share from my research.

That looks like what was referred to as 'balcony genioplasty' prior on this board by member; 'mcjawsurgery' who said Sinn would do for him but then he ended up having genio in Korea.