Just had a bimax to cure Sleep Apnea - were the performed movements needed ?

[Baguettejaws]

Hello Guys ! 

First post there. 35y old, Sleep Apena (25 per hour).
I had consultations with several doctors, including DeFrancq in Belgium and finally decided to go to a french maxilofacial surgeon near Paris. My bite was class 1 so they decided they can operate without ortho.
I underwent a Bimax two weeks ago, and during my time off, I tried to better understand what all sort of movements when performing a bimax. Here is my pics preop

1) Given the ceph and pictures, what would have been the best movements to perform ? I got straightforward MMA (10mm) with standard zygo or infraorbital implants. When I asked the surgeron about a possible rotation, he told me "you don't have a gummy smile"

I told myself that maybe he did'nt think it was a geat idea as my occlusal plane were not so steep but I am not sure about that

2) In all the beautiful outcomes I see on the forum, it seems that there is a vertical line passing by the maxila and the mandibule. In my case, pre-op, the line is "tilted". How comes moving both maxilia the same amount of mm is going to create that straight line ?

I am currently wondering if I did the best choice regarding the surgeon/procedure in order to achieve facial harmony, as I see a lot of surgeries involve CCW to minimize the advancement of the upper/maximize lower advancement. I am afraid the 10 mm advancement may have been to much regarding the cephs.

[GJ]

Are the records you posted all pre-op?

That second one is useless. The angle is not correct, and drawings like that are old school and not good, modern records of any value. The x-ray shows a good dental relationship, so his idea of no ortho is probably correct, but how is your bite after surgery?

If your final photo is pre-op, then I think you could have gone the route of linear movement or CCW movement. I think either would work, though I think 10mm is too much for a linear movement. If he wanted to do linear only I'd cap that at 5mm before you risk the chimp look. Linear is more old school, and that fits with what I'm seeing with that drawing. Was your surgeon and old guy? Given how flat and long your philtrum is, I'd think CCW would give a better result. If you have better records please post them.

[Baguettejaws]

Thank for your fast reply.
 
The drawing come from a first surgeon I consulted that I did not move forward with, I brought it to the surgeon that did the bimax and he did not seemed to be interested with this document, Ceph and other X rays were more appealing to him/
Regarding the bite, I still have elastic bands but it seems to be ok from what I see.

All the records are pre-op. I can share a post-op simulation and then a post-op picture, 2 weeks after to see whether or not the result seems promising.
edit : surgeon is 45 I think, but the exams he asked before surgery were just ceph, dental panoramic, I also gave him MRI but he did not asked more exams.

[ArtVandelay]

I don't know if it's just my monitor but that ceph appears useless; I can't see anything.

[kavan]

Hello Guys ! 

First post there. 35y old, Sleep Apena (25 per hour).
I had consultations with several doctors, including DeFrancq in Belgium and finally decided to go to a french maxilofacial surgeon near Paris. My bite was class 1 so they decided they can operate without ortho.
I underwent a Bimax two weeks ago, and during my time off, I tried to better understand what all sort of movements when performing a bimax. Here is my pics preop

1) Given the ceph and pictures, what would have been the best movements to perform ? I got straightforward MMA (10mm) with standard zygo or infraorbital implants. When I asked the surgeron about a possible rotation, he told me "you don't have a gummy smile"

I told myself that maybe he did'nt think it was a geat idea as my occlusal plane were not so steep but I am not sure about that

2) In all the beautiful outcomes I see on the forum, it seems that there is a vertical line passing by the maxila and the mandibule. In my case, pre-op, the line is "tilted". How comes moving both maxilia the same amount of mm is going to create that straight line ?

I am currently wondering if I did the best choice regarding the surgeon/procedure in order to achieve facial harmony, as I see a lot of surgeries involve CCW to minimize the advancement of the upper/maximize lower advancement. I am afraid the 10 mm advancement may have been to much regarding the cephs.

Elementary Geometry. A straight line, by definition, is a line made by connecting 2 points.
A diagonal line is just as 'straight' as a vertical one. So, not something where only a vertical line is straight.

When 2 lines are perpendicular to each other, they intersect at a 90 degree angle. So, 2 diagonal lines can also be perpendicular to each other when they intersect at a 90 degree angle. THAT'S what your ceph diagram is showing.

The line passing through the maxilla from points; ANS-PNS is about parallel to the Frankfurt Horizontal. The ceph is conveying that because the more vertically oriented line passes through the 'Or' point. So, a line parallel to the one passing through the maxilla would be perpendicular to the more vertically oriented line and most likely passes through the 'po' point of the Frankfurt Horizonatal which is Po-Or.

So, if one wanted to reproduce the 'vertical' line you might see in other cephs, it would be drawn PARALLEL to the more vertically oriented (longer) line on yours so that it passed through where the base of the nose meets the upper lip area.

If I ROTATED your CEPH about 16 degrees CCW, the short line going through your maxilla would be HORIZONTAL and the longer line PERPENDICULAR to it would be VERTICAL (in direction of line of gravity). A line PARALLEL to the vertical that PASSED THROUGH where the base of the nose meets the upper lip area would be what they call the 'TVL' or 'true vertical line which would show that your chin point (pog) is BEHIND the line and so are your lips.

The ceph tracing also shows the bite is right which is an indication in favor of linear advancement, especially for a sleep apnea case. So, that coupled with the other thing the ceph shows; the line through the maxilla being parallel to the Frankfurt Horizont is an also an indication in favor of an overall linear advancement parallel to the Franfurt Horizont.

I wouldn't say the ceph tracing was 'useless'. Was useful enough for me to know what it was conveying.

[GJ]

he did not seemed to be interested with this document

Okay good. It's nothing more than glorified art class.
I'd be curious to see some post-op records, yes.

[Baguettejaws]

@Kavan, @GJ, thank you for your replies.

As promised, you'll find below  two ost-op picture, +15 and +16 days after the bimax. The +16 picture show my head that is slightly tilted.


Well, I do not really know what to think. I don't really like what I see and I am wondering if this is because of the swelling that is more pronounced on the areas that have been directly affected by the surgery, or if we can already say that something is odd.

[kavan]

Well, I'd ask if the surgery resulted in better breathing. It's common for one to see swelling right under the nose. Perhaps the conVEXity to it will flatten out somewhat with time.  The surgeon/s saw an indication for the MMA linear advancement which is when the bite is right for them to move things equally.

[InvisalignOnly]

16 days after surgery is waaaay too early to judge the aesthetic outcome. I could not even see the outlines of my 'new face' at that stage, it was just one big swollen potato head. You have to wait several more weeks to get an idea of what the final result will look like. As Kavan says, the more important thing at this stage is, is your functional result good, from what you can tell so far?

[GJ]

You look very different, but I don't think it's worse or better. Just a different look. Before you looked more nerdy and boyish, and now you look like a man. I'd imagine that's very dramatic for you to deal with since it's so drastic. Give it time to heal and to adjust, and also to realize you had to do this surgery for your health.

Can you seal your lips without strain after?

[Gadwins]

Is it even possible to judge the after pictures? The only thing what is obvious is the philtrum area, but the rest is hidden under the beard. Even my surgeon wanted me to shave before the surgery, so he could see the real me.

Besides, it is not even the same side of the face.

[GJ]

Is it even possible to judge the after pictures?

Yes.

But not 100% apples to apples. We get the general idea.

[Baguettejaws]

Hello Guys,

Thank you for your qualitative replies.
I come back with some news. As usual, feel free to ask me to clarify my wording as I am not an english native speaker.

Regarding the sleep anpea/snoring

I stopped using the CPAP machine the day after surgery.
I used to monitor my snoring with an app "Ironfle" which means "I snore". My score went from 70 (without CPAP) to 3 after surgery. The recording shows absolutely no snoring, which is nice. For the sleep apnea, as I did not had polysomnography yet, I am still guessing but here is what I can feel
I no longer need 11 hours sleep, 7 hours works fine
I wake up with a slight headeache, which is usually a sign of sleep apnea. However, I force myself to sleep with a closed mouth, and I still feel a swelling inside my nose. If my mouth is opened, no headache at all, which was not the case before surgery
My partner says that she does not see any apnea at all (she stayed awake 2 hours when I was sleeping)
I no longer feel tired during the day
@GJ I can seal my lips without strain right now

Regarding the aesthetical outcome

The swelling is still here, I am going to post a picture the 24th, one month after the surgery. I'll be shaving the beard.
I am a little bit concerned by the appearance of the cheek implants. It seems that the placement is a little bit off, but again, I am going to wait and see what happens.

By the way, you'll find enclosed a proper pre-op ceph, the previous one was very dark, thanks Kavan for your analysis despite the poor material I provided.

[Baguettejaws]

Hello guys

Just a little update about my surgery.
I had an appointement with the surgeron. He seems satisfied with his job.

Here were my concerns :

Cheeks implants seems to have a weird look
Maxila seems proeminent
Bite not perfect ( maxila seems to be more advanced that the mandible). To give you an idea, if I take a surgeon mask and bite the elastics with my front teeths, they can slip out of my months. Nice job, especially when I was class 1 before the surgery.
A little bit gummy smile

Surgeon answer "wait more, it is going to fix itself"

I had some concerns about the outcome so I decided to do some cephs post op to bring it to another surgeron

The other surgeron looked at my face and cephs and said that the maxila was probably over advanced, that the cheeks were to be removed (wrong position) and too big (werent tailor made but off the shelf) and that the bite is incorrect.

He suggest that I come back in a few months, once everything is stabilized, in order to

Remove the cheeks implants
Perform movements on the jaws (impaction/rotation in order to restore the bite and show less gum)


Conclusion : chose your surgeron wisely. Even the big names are sometime not really reliable for a surgery on a "simple case".

Enclosed : a before/after. Note : the before was a scan of my preop and the after is simply the ceph that I put on the computer screen. So the material is unusable for any analysis, I just wanted to give you a general idea as soon as possible.

[kavan]

I've never seen cephs like that with someone's reflection in the background. So perfectly understandable, they can't be used for much feed back here. If you are still in braces, the objective would be towards final bite corrections which is why both are telling you to wait.

As to choosing a surgeon wisely, it would be the choice of the SECOND one that you have to be wiser about.